Healthcare Provider Details

I. General information

NPI: 1225414121
Provider Name (Legal Business Name): SALAR AND DELISLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2015
Last Update Date: 08/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3160 N TRUCKEE LN
SPARKS NV
89434-1583
US

IV. Provider business mailing address

3160 N TRUCKEE LN
SPARKS NV
89434-1583
US

V. Phone/Fax

Practice location:
  • Phone: 310-968-0562
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberS6-120
License Number StateNV

VIII. Authorized Official

Name: BEN SALAR
Title or Position: MANAGING MEMBER
Credential:
Phone: 310-968-0562