Healthcare Provider Details

I. General information

NPI: 1124568043
Provider Name (Legal Business Name): PROVIDENCE ORTHODONTICS DHILLON PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2017
Last Update Date: 02/20/2023
Certification Date: 02/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7181 N HUALAPAI WAY 105
LAS VEGAS NV
89166-1115
US

IV. Provider business mailing address

7181 N HUALAPAI WAY 105
LAS VEGAS NV
89166-1115
US

V. Phone/Fax

Practice location:
  • Phone: 702-852-1818
  • Fax: 702-947-5088
Mailing address:
  • Phone: 702-852-1818
  • Fax: 702-947-5088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberS681
License Number StateNV

VIII. Authorized Official

Name: TIFFANY LORICK
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 704-806-3632