Healthcare Provider Details

I. General information

NPI: 1225218951
Provider Name (Legal Business Name): RADIANT DENTAL 1
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2007
Last Update Date: 11/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7469 W LAKE MEAD BLVD SUITE 270
LAS VEGAS NV
89128-1030
US

IV. Provider business mailing address

7469 W LAKE MEAD BLVD SUITE 270
LAS VEGAS NV
89128-1030
US

V. Phone/Fax

Practice location:
  • Phone: 702-312-8710
  • Fax:
Mailing address:
  • Phone: 702-312-8710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number4480
License Number StateNV

VIII. Authorized Official

Name: DAVID C GONZALEZ
Title or Position: OWNER
Credential:
Phone: 702-610-5458