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General NPI Number Information
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NPI Number | 1174053078
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Entity Type | Individual
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Provider Name | KORY GRAHL DMD
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Gender | Male
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Dates
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Enumeration Date | 06/14/2017
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Last Update Date | 03/05/2024
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Provider Practice Location Address
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Address Line | 1700 W CHARLESTON BLVD BLDG D
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City | LAS VEGAS
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State | NV
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Zip | 89102-2335
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Country | US
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Telephone | 858-382-2633
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Fax |
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Provider Business Mailing Address
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Address Line | 12397 SHORELINE ECHO AVE
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City | LAS VEGAS
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State | NV
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Zip | 89138-6184
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Country | US
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Telephone |
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | LL-548-21
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License Number State | NV
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 101397
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 33969
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License Number State | TX
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Taxonomy #4
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 7695
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License Number State | NV
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