Healthcare Provider Details

I. General information

NPI: 1235329210
Provider Name (Legal Business Name): MILES OF SMILES VENTURES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2007
Last Update Date: 03/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4040 N. MARTIN LUTHER KING STE B.
LAS VEGAS NV
89032-3205
US

IV. Provider business mailing address

4040 N. MARTIN LUTHER KING STE B.
LAS VEGAS NV
89032-3205
US

V. Phone/Fax

Practice location:
  • Phone: 702-639-3515
  • Fax: 702-639-3516
Mailing address:
  • Phone: 702-639-3515
  • Fax: 702-639-3516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4522T
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4522T
License Number StateNV

VIII. Authorized Official

Name: SHERILL BANKS
Title or Position: OFFICE MANAGER
Credential:
Phone: 702-639-3515