Healthcare Provider Details

I. General information

NPI: 1457936163
Provider Name (Legal Business Name): JFK ORTHODONTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2021
Last Update Date: 04/10/2021
Certification Date: 04/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7140 N DURANGO DR STE 110
LAS VEGAS NV
89149-4473
US

IV. Provider business mailing address

7140 N DURANGO DR STE 110
LAS VEGAS NV
89149-4473
US

V. Phone/Fax

Practice location:
  • Phone: 702-740-8437
  • Fax:
Mailing address:
  • Phone: 702-740-8437
  • 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: TIFFANY LORICK
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 919-948-6787