Healthcare Provider Details

I. General information

NPI: 1922767276
Provider Name (Legal Business Name): BRANHAM DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2021
Last Update Date: 12/14/2021
Certification Date: 12/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4610 MEADOWS LN STE B
LAS VEGAS NV
89107-2965
US

IV. Provider business mailing address

4610 MEADOWS LN STE B
LAS VEGAS NV
89107-2965
US

V. Phone/Fax

Practice location:
  • Phone: 702-878-7700
  • Fax: 702-878-4630
Mailing address:
  • Phone: 702-878-7700
  • Fax: 702-878-4630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: STEVE BRANHAM
Title or Position: OWNER
Credential:
Phone: 702-878-7700