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General NPI Number Information
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NPI Number | 1073963757
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Entity Type | Organization
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Legal Business Name | ABRAZA DENTAL GROUP LLC
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Dates
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Enumeration Date | 06/14/2016
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Last Update Date | 06/15/2016
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Provider Practice Location Address
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Address Line | 5642 S EASTERN AVE SUITE B
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City | LAS VEGAS
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State | NV
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Zip | 89119-2375
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Country | US
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Telephone | 702-456-0005
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Fax |
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Provider Business Mailing Address
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Address Line | 5642 S EASTERN AVE SUITE B
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City | LAS VEGAS
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State | NV
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Zip | 89119-2375
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Country | US
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Telephone | 702-456-0005
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Fax |
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Authorized Official
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Title or Position | DDS
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Name | WYATT STOTT DANNELS
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Credential | DDS
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Telephone | 702-456-0005
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 6743
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License Number State | NV
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