=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295252559
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | A PLUS DENTAL GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2017
-----------------------------------------------------
Last Update Date | 08/28/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4226 S DURANGO DR
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89147-8721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-522-9192
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2285 E FLAMINGO RD
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89119-5100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-522-9192
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DR. LEILA KHOSSOOSI
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 702-522-9192
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------