Healthcare Provider Details

I. General information

NPI: 1487828356
Provider Name (Legal Business Name): LAS VEGAS ORAL SURGERY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2008
Last Update Date: 04/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7670 W LAKE MEAD BLVD SUITE 130
LAS VEGAS NV
89128-6649
US

IV. Provider business mailing address

7670 W LAKE MEAD BLVD SUITE 130
LAS VEGAS NV
89128-6649
US

V. Phone/Fax

Practice location:
  • Phone: 702-312-2273
  • Fax: 702-312-2276
Mailing address:
  • Phone: 702-312-2273
  • Fax: 702-312-2276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberS2-26
License Number StateNV

VIII. Authorized Official

Name: KEVIN M MARTIN
Title or Position: OWNER
Credential: DDS
Phone: 702-204-8862