Healthcare Provider Details

I. General information

NPI: 1457496077
Provider Name (Legal Business Name): THE DENTAL IMPLANT SOURCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8960 W CHEYENNE AVE UNIT 190
LAS VEGAS NV
89129-8929
US

IV. Provider business mailing address

8960 W CHEYENNE AVE UNIT 190
LAS VEGAS NV
89129-8929
US

V. Phone/Fax

Practice location:
  • Phone: 702-367-4121
  • Fax: 702-367-4021
Mailing address:
  • Phone: 702-367-4121
  • Fax: 702-367-4021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number2543
License Number StateNV

VIII. Authorized Official

Name: DR. LYLE SCOTT BROOKSBY
Title or Position: PRESIDENT
Credential: DDS
Phone: 702-367-4121