Healthcare Provider Details

I. General information

NPI: 1205169034
Provider Name (Legal Business Name): NICOLE LEILA MACKIE DDS, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2009
Last Update Date: 09/14/2021
Certification Date: 09/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8840 W RUSSELL RD STE 210
LAS VEGAS NV
89148-1355
US

IV. Provider business mailing address

8840 W RUSSELL RD STE 210
LAS VEGAS NV
89148-1355
US

V. Phone/Fax

Practice location:
  • Phone: 702-463-1300
  • Fax: 702-463-4633
Mailing address:
  • Phone: 702-463-1300
  • Fax: 702-463-4633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN18071
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDI024233
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number055160-1
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberS543C
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: