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General NPI Number Information
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NPI Number | 1114454097
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Entity Type | Organization
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Legal Business Name | LEGENDARY SMILES ORTHODONTICS LLC
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Dates
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Enumeration Date | 05/22/2017
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Last Update Date | 03/17/2018
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Provider Practice Location Address
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Address Line | 5220 NEIL RD. STE. 110
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City | RENO
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State | NV
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Zip | 89502
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Country | US
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Telephone | 775-336-1510
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Fax | 775-336-1510
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Provider Business Mailing Address
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Address Line | 3605 GRANT DR
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City | RENO
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State | NV
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Zip | 89509-5301
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Country | US
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Telephone | 775-336-1510
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Fax | 775-432-6001
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Authorized Official
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Title or Position | MANAGER
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Name | NATE ROCKWELL
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Credential |
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Telephone | 775-336-1510
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number |
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License Number State |
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