Healthcare Provider Details

I. General information

NPI: 1609568708
Provider Name (Legal Business Name): KATELYN SUE COURIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2023
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 SHADOW LN
LAS VEGAS NV
89106-4124
US

IV. Provider business mailing address

1001 SHADOW LN
LAS VEGAS NV
89106-4124
US

V. Phone/Fax

Practice location:
  • Phone: 702-774-2545
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberLL63726
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: