Healthcare Provider Details

I. General information

NPI: 1902977168
Provider Name (Legal Business Name): GIRIDHARA K CHITTIVELU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 06/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

526 S TONOPAH DR STE. 200
LAS VEGAS NV
89106-4043
US

IV. Provider business mailing address

526 S TONOPAH DR STE. 200
LAS VEGAS NV
89106-4043
US

V. Phone/Fax

Practice location:
  • Phone: 702-291-2031
  • Fax: 702-366-1483
Mailing address:
  • Phone: 702-291-2031
  • Fax: 702-366-1483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number21385
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberS3-264
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: