Healthcare Provider Details

I. General information

NPI: 1205460334
Provider Name (Legal Business Name): CELEBRACES DECATUR LOVELAND PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2020
Last Update Date: 03/13/2020
Certification Date: 03/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4880 W FLAMINGO RD
LAS VEGAS NV
89103-3704
US

IV. Provider business mailing address

4880 W FLAMINGO RD
LAS VEGAS NV
89103-3704
US

V. Phone/Fax

Practice location:
  • Phone: 702-687-7000
  • Fax: 702-947-6655
Mailing address:
  • Phone: 702-687-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: ARIANNA FERRALL
Title or Position: ORTHODONTIC TREATMENT COORDINATOR
Credential:
Phone: 562-397-9279