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General NPI Number Information
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NPI Number | 1154786929
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Entity Type | Organization
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Legal Business Name | MICHAEL R WANLASS DDS LTD
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Dates
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Enumeration Date | 12/22/2015
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Last Update Date | 12/22/2015
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Provider Practice Location Address
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Address Line | 2625 S RAINBOW BLVD SUITE C-100
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City | LAS VEGAS
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State | NV
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Zip | 89146-5198
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Country | US
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Telephone | 702-367-4412
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Fax |
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Provider Business Mailing Address
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Address Line | 2625 S RAINBOW BLVD SUITE C-100
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City | LAS VEGAS
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State | NV
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Zip | 89146-5198
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Country | US
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Telephone | 702-367-4412
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MICHAEL WANLASS
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Credential | DDS
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Telephone | 702-367-4412
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number | 2287
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License Number State | NV
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