Healthcare Provider Details

I. General information

NPI: 1255347803
Provider Name (Legal Business Name): DOUGLAS K. SIMISTER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 02/21/2025
Certification Date: 02/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6710 S FORT APACHE RD # 101
LAS VEGAS NV
89148-5394
US

IV. Provider business mailing address

6710 S FORT APACHE RD # 101
LAS VEGAS NV
89148-5394
US

V. Phone/Fax

Practice location:
  • Phone: 702-254-4335
  • Fax:
Mailing address:
  • Phone: 702-254-4335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number3196
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: