Healthcare Provider Details

I. General information

NPI: 1922533785
Provider Name (Legal Business Name): PROVIDENCE DENTAL DHILLON PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2017
Last Update Date: 04/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10965 LAVENDER HILL DR # 6200
LAS VEGAS NV
89135-2950
US

IV. Provider business mailing address

10965 LAVENDER HILL DR # 6200
LAS VEGAS NV
89135-2950
US

V. Phone/Fax

Practice location:
  • Phone: 702-852-2755
  • Fax: 702-947-4944
Mailing address:
  • Phone: 702-852-2755
  • Fax: 702-947-4944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberS6-81
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberS6-81
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberS6-81
License Number StateNV
# 4
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberS6-81
License Number StateNV

VIII. Authorized Official

Name: GURBRINDER DHILLON
Title or Position: OWNER
Credential:
Phone: 702-852-2755