Healthcare Provider Details

I. General information

NPI: 1467842302
Provider Name (Legal Business Name): ADVENTURE SMILES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2015
Last Update Date: 01/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8995 W FLAMINGO RD SUITE 100
LAS VEGAS NV
89147-0441
US

IV. Provider business mailing address

8995 WEST FLAMINGO ROAD SUITE 100
LAS VEGAS NV
89147
US

V. Phone/Fax

Practice location:
  • Phone: 702-838-5437
  • Fax: 702-838-5434
Mailing address:
  • Phone: 702-838-5437
  • Fax: 702-838-5434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberS6-129
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberS6-49
License Number StateNV

VIII. Authorized Official

Name: DR. GARY D RICHARDSON
Title or Position: PRESIDENT
Credential: DDS
Phone: 702-878-5437