Healthcare Provider Details

I. General information

NPI: 1306338033
Provider Name (Legal Business Name): LIE CHARLESTON SMILES DENTISTRY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2018
Last Update Date: 02/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 S NELLIS BLVD STE 200
LAS VEGAS NV
89104-5700
US

IV. Provider business mailing address

17000 RED HILL AVE
IRVINE CA
92614-5626
US

V. Phone/Fax

Practice location:
  • Phone: 714-845-8500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: WANNI LIE
Title or Position: OWNER
Credential:
Phone: 714-845-8500