Healthcare Provider Details

I. General information

NPI: 1730181850
Provider Name (Legal Business Name): NELSON D LASITER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2255 RENAISSANCE DR STE B
LAS VEGAS NV
89119-6167
US

IV. Provider business mailing address

2255 RENAISSANCE DR STE B
LAS VEGAS NV
89119-6167
US

V. Phone/Fax

Practice location:
  • Phone: 702-798-1987
  • Fax:
Mailing address:
  • Phone: 702-798-1987
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberS5-04
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: