=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225163959
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NANTIYA JOE LIMITED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9155 W FLAMINGO RD 120
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89147-6894
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-838-8112
-----------------------------------------------------
Fax | 702-838-1907
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9155 W FLAMINGO RD 120
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89147-6894
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-838-8112
-----------------------------------------------------
Fax | 702-838-1907
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. NANTIYA H JOE
-----------------------------------------------------
Credential | D.D.S, M.S.
-----------------------------------------------------
Telephone | 702-838-8112
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 3225
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------