Healthcare Provider Details

I. General information

NPI: 1720592140
Provider Name (Legal Business Name): LEAVER AND GARDNER ORTHODONTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5765 CENTENNIAL CENTER BLVD STE 110
LAS VEGAS NV
89149-7125
US

IV. Provider business mailing address

5765 CENTENNIAL CENTER BLVD STE 110
LAS VEGAS NV
89149-7125
US

V. Phone/Fax

Practice location:
  • Phone: 702-878-0764
  • Fax:
Mailing address:
  • Phone:
  • 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: MICHAEL GARDNER
Title or Position: PARTNER
Credential:
Phone: 702-234-5717