Healthcare Provider Details

I. General information

NPI: 1558764456
Provider Name (Legal Business Name): UNLV ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2014
Last Update Date: 10/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 SHADOW LN
LAS VEGAS NV
89106-4124
US

IV. Provider business mailing address

4471 DEAN MARTIN DR APT 3209
LAS VEGAS NV
89103-4251
US

V. Phone/Fax

Practice location:
  • Phone: 702-706-4270
  • Fax:
Mailing address:
  • Phone: 201-264-5671
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number6528
License Number StateNV

VIII. Authorized Official

Name: DR. JAMES MAH
Title or Position: PROGRAM DIRECTOR
Credential: DMD
Phone: 702-774-2698