Healthcare Provider Details

I. General information

NPI: 1013216340
Provider Name (Legal Business Name): SUSAN E LEGRAND RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2011
Last Update Date: 03/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3074 ARVILLE ST
LAS VEGAS NV
89102-7490
US

IV. Provider business mailing address

3074 ARVILLE ST
LAS VEGAS NV
89102-7490
US

V. Phone/Fax

Practice location:
  • Phone: 702-889-3763
  • Fax:
Mailing address:
  • Phone: 702-889-3763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number3646
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: