Healthcare Provider Details

I. General information

NPI: 1023263365
Provider Name (Legal Business Name): MRDNTD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2008
Last Update Date: 01/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3575 S. TOWN CENTER DR. SUITE 120
LAS VEGAS NV
89135
US

IV. Provider business mailing address

3575 S. TOWN CENTER DR. #120
LAS VEGAS NV
89135
US

V. Phone/Fax

Practice location:
  • Phone: 702-869-5700
  • Fax: 702-869-6657
Mailing address:
  • Phone: 702-869-5700
  • Fax: 702-869-6657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3502
License Number StateNV

VIII. Authorized Official

Name: PROF. JOHN SOUMI
Title or Position: MANAGER
Credential: DDS
Phone: 702-869-5700