Healthcare Provider Details

I. General information

NPI: 1750637096
Provider Name (Legal Business Name): RENO ORAL & MAXILLOFACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2012
Last Update Date: 07/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5420 KIETZKE LN STE 102
RENO NV
89511-2063
US

IV. Provider business mailing address

5420 KIETZKE LN STE 102
RENO NV
89511-2063
US

V. Phone/Fax

Practice location:
  • Phone: 775-853-9696
  • Fax: 775-853-9695
Mailing address:
  • Phone: 775-853-9696
  • Fax: 775-853-9695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number6268
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberS295C
License Number StateNV

VIII. Authorized Official

Name: DR. RICK J RAWSON
Title or Position: OWNER
Credential: D.D.S.,.M.S.
Phone: 775-853-9696