Healthcare Provider Details

I. General information

NPI: 1679639710
Provider Name (Legal Business Name): ENDODONTIC ASSOCIATESLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

851 S RAMPART BLVD SUITE # 120
LAS VEGAS NV
89145-4882
US

IV. Provider business mailing address

851 S RAMPART BLVD SUITE # 120
LAS VEGAS NV
89145-4882
US

V. Phone/Fax

Practice location:
  • Phone: 702-869-8840
  • Fax: 702-240-0481
Mailing address:
  • Phone: 702-869-8840
  • Fax: 702-240-0481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberS7-24
License Number StateNV

VIII. Authorized Official

Name: DR. DOUGLAS R RAKICH
Title or Position: MANAGER
Credential: DDS
Phone: 702-869-8840