Healthcare Provider Details

I. General information

NPI: 1063606580
Provider Name (Legal Business Name): SIMISTER PREMIER ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2007
Last Update Date: 02/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2430 E HARMON AVE SUITE 3
LAS VEGAS NV
89121-5338
US

IV. Provider business mailing address

4306 S EASTERN AVE
LAS VEGAS NV
89119-6016
US

V. Phone/Fax

Practice location:
  • Phone: 702-735-4169
  • Fax: 702-735-8697
Mailing address:
  • Phone: 702-735-4169
  • Fax: 702-735-8697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberS3153
License Number State

VIII. Authorized Official

Name: DR. DOUGLAS K SIMISTER
Title or Position: OWNER
Credential: D.D.S.
Phone: 702-735-4169