Healthcare Provider Details

I. General information

NPI: 1639736259
Provider Name (Legal Business Name): CHAO SUO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2019
Last Update Date: 05/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 E DEER SPRINGS WAY STE 180
NORTH LAS VEGAS NV
89086-1514
US

IV. Provider business mailing address

7401 W WASHINGTON AVE APT 1114
LAS VEGAS NV
89128-4310
US

V. Phone/Fax

Practice location:
  • Phone: 702-399-3800
  • Fax:
Mailing address:
  • Phone: 605-202-9045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7221
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: