Healthcare Provider Details

I. General information

NPI: 1063900595
Provider Name (Legal Business Name): SUMMIT BOULEVARD DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2018
Last Update Date: 04/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13985 S VIRGINIA ST STE 806
RENO NV
89511-8934
US

IV. Provider business mailing address

13985 S VIRGINIA ST STE 806
RENO NV
89511-8934
US

V. Phone/Fax

Practice location:
  • Phone: 775-846-4777
  • Fax: 775-525-5512
Mailing address:
  • Phone: 775-846-4777
  • Fax: 775-525-5512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberS7-881
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberS7-88C
License Number StateNV

VIII. Authorized Official

Name: DR. TIMOTHY ADAMS
Title or Position: OWNER
Credential: DMD
Phone: 615-601-4728