Healthcare Provider Details

I. General information

NPI: 1144842626
Provider Name (Legal Business Name): POUYA MOMTAZ DMD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2020
Last Update Date: 05/07/2020
Certification Date: 05/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6121 W LAKE MEAD BLVD STE 115
LAS VEGAS NV
89108-2737
US

IV. Provider business mailing address

6121 W LAKE MEAD BLVD STE 115
LAS VEGAS NV
89108-2737
US

V. Phone/Fax

Practice location:
  • Phone: 702-381-9444
  • Fax:
Mailing address:
  • Phone: 702-381-9444
  • 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. POUYA MOMTAZ
Title or Position: ORTHODONTIST
Credential: DMD. MS
Phone: 702-546-9936