Healthcare Provider Details

I. General information

NPI: 1669207957
Provider Name (Legal Business Name): MODERN DENTAL SPECIALIST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2024
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4416 E BONANZA RD UNIT 120
LAS VEGAS NV
89110-6349
US

IV. Provider business mailing address

4618 MEADOWS LN
LAS VEGAS NV
89107-2956
US

V. Phone/Fax

Practice location:
  • Phone: 702-200-9000
  • Fax:
Mailing address:
  • Phone: 702-200-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: BENNY KOHANTEB
Title or Position: DENTIST
Credential: DDS
Phone: 818-631-3368