Healthcare Provider Details

I. General information

NPI: 1033965991
Provider Name (Legal Business Name): ORTHOBAR, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2024
Last Update Date: 04/30/2024
Certification Date: 04/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6425 S DURANGO DR STE 120
LAS VEGAS NV
89113-7113
US

IV. Provider business mailing address

6425 S DURANGO DR STE 120
LAS VEGAS NV
89113-7113
US

V. Phone/Fax

Practice location:
  • Phone: 702-757-5355
  • Fax:
Mailing address:
  • Phone: 702-757-5355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. KORY GRAHL
Title or Position: OWNER, PARTNER
Credential: DMD, MS
Phone: 858-382-2633