Healthcare Provider Details

I. General information

NPI: 1760812622
Provider Name (Legal Business Name): VISTA SMILE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2013
Last Update Date: 06/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 S RAINBOW BLVD 101
LAS VEGAS NV
89146
US

IV. Provider business mailing address

2101 S JONES BLVD STE 140
LAS VEGAS NV
89146-3133
US

V. Phone/Fax

Practice location:
  • Phone: 702-733-7645
  • Fax: 702-823-0410
Mailing address:
  • Phone: 702-522-2269
  • Fax: 702-990-8856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberS3-82C
License Number StateNV

VIII. Authorized Official

Name: ROLAND PISCHINGER
Title or Position: INSURANCE DEPARTMENT MANAGER
Credential:
Phone: 702-522-2028