Healthcare Provider Details

I. General information

NPI: 1891441762
Provider Name (Legal Business Name): CPD SOUTH MEADOWS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2022
Last Update Date: 08/30/2023
Certification Date: 08/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5435 KIETZKE LN STE 100
RENO NV
89511-1088
US

IV. Provider business mailing address

255 GLENDALE AVE STE 3
SPARKS NV
89431-5777
US

V. Phone/Fax

Practice location:
  • Phone: 775-237-2038
  • Fax: 775-359-4034
Mailing address:
  • Phone: 775-636-9939
  • Fax: 775-737-4002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: JASON CHAMPAGNE
Title or Position: OWNER
Credential: DDS
Phone: 775-636-9939