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General NPI Number Information
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NPI Number | 1104175272
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Entity Type | Individual
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Provider Name | DEBORHA LYNN STATEN D.M.D.
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Gender | Female
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Dates
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Enumeration Date | 09/05/2012
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Last Update Date | 10/20/2020
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Provider Practice Location Address
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Address Line | 5475 S FORT APACHE RD STE 100
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City | LAS VEGAS
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State | NV
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Zip | 89148-6410
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Country | US
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Telephone | 702-736-7979
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Fax | 702-736-5851
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Provider Business Mailing Address
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Address Line | 680 PROSSER CREEK PL
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City | HENDERSON
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State | NV
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Zip | 89002-0953
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Country | US
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Telephone | 702-595-6505
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 6292
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License Number State | NV
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