Healthcare Provider Details

I. General information

NPI: 1881823789
Provider Name (Legal Business Name): KLINE C BLACK D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2009
Last Update Date: 12/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E DESERT INN RD STE #3
LAS VEGAS NV
89169-2550
US

IV. Provider business mailing address

1500 E DESERT INN RD STE #3
LAS VEGAS NV
89169-2550
US

V. Phone/Fax

Practice location:
  • Phone: 702-642-8101
  • Fax: 702-642-1131
Mailing address:
  • Phone: 702-642-8101
  • Fax: 702-642-1131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5852
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: