Healthcare Provider Details

I. General information

NPI: 1629164769
Provider Name (Legal Business Name): NEVADA ORTHODONTIC CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 S RAINBOW BLVD 101
LAS VEGAS NV
89146-4006
US

IV. Provider business mailing address

2600 S RAINBOW BLVD 101
LAS VEGAS NV
89146-4006
US

V. Phone/Fax

Practice location:
  • Phone: 702-733-7645
  • Fax:
Mailing address:
  • Phone: 702-733-7645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number4332
License Number StateNV

VIII. Authorized Official

Name: BRIAN RANDLE
Title or Position: DOCTOR
Credential: DDS
Phone: 801-541-9504