=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043582810
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ERNESTO BARBOSA DMD, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2012
-----------------------------------------------------
Last Update Date | 02/08/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1264 S NELLIS BLVD
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89104-5782
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-243-2489
-----------------------------------------------------
Fax | 702-438-4428
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1264 S NELLIS BLVD
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89104-5782
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-243-2489
-----------------------------------------------------
Fax | 702-438-4428
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ERNESTO BARBOSA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 702-278-0876
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 6060
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 8361
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------