Healthcare Provider Details

I. General information

NPI: 1144267782
Provider Name (Legal Business Name): JOHN JOSEPH DUDEK D.D.S., M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6970 SMOKE RANCH RD SUITE 150
LAS VEGAS NV
89128
US

IV. Provider business mailing address

2108 MERGANSER CT
NORTH LAS VEGAS NV
89084-2843
US

V. Phone/Fax

Practice location:
  • Phone: 702-259-6729
  • Fax:
Mailing address:
  • Phone: 702-656-4045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberS2-45
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: