Healthcare Provider Details

I. General information

NPI: 1164646295
Provider Name (Legal Business Name): GREGG R KOLEBUCK DDS LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 03/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1811 S RAINBOW BLVD STE 202
LAS VEGAS NV
89146-0855
US

IV. Provider business mailing address

1811 S RAINBOW BLVD STE 202
LAS VEGAS NV
89146-0855
US

V. Phone/Fax

Practice location:
  • Phone: 702-838-5400
  • Fax: 702-838-5031
Mailing address:
  • Phone: 702-838-5400
  • Fax: 702-838-5031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3337
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. GREGG R KOLEBUCK
Title or Position: DENTIST / OWNER
Credential: DDS
Phone: 702-838-5400