Healthcare Provider Details

I. General information

NPI: 1720346117
Provider Name (Legal Business Name): NORTHERN NEVADA DENTAL SPECIALTIES GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2012
Last Update Date: 11/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10645 DOUBLE R BLVD
RENO NV
89521-8920
US

IV. Provider business mailing address

10645 DOUBLE R BLVD
RENO NV
89521-8920
US

V. Phone/Fax

Practice location:
  • Phone: 775-852-6164
  • Fax: 775-284-7352
Mailing address:
  • Phone: 775-852-6164
  • Fax: 775-284-7352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberS6-20
License Number StateNV

VIII. Authorized Official

Name: DR. J JUSTIN WILKERSON
Title or Position: MANAGER
Credential: DDS
Phone: 775-823-9797