Healthcare Provider Details

I. General information

NPI: 1871639831
Provider Name (Legal Business Name): NEVADA TMJ INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 08/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 LAKE SAHARA DR 120
LAS VEGAS NV
89117-3451
US

IV. Provider business mailing address

2650 LAKE SAHARA DR 120
LAS VEGAS NV
89117-3451
US

V. Phone/Fax

Practice location:
  • Phone: 702-259-4865
  • Fax: 702-243-7581
Mailing address:
  • Phone: 702-259-4865
  • Fax: 702-243-7581

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2679
License Number StateNV

VIII. Authorized Official

Name: DR. MARK JOHN ESCOTO
Title or Position: DENTIST
Credential: D.D.S.
Phone: 702-259-4865