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General NPI Number Information
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NPI Number | 1366811747
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Entity Type | Organization
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Legal Business Name | LONE MOUNTAIN FAMILY DENTAL
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Dates
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Enumeration Date | 09/16/2015
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Last Update Date | 09/16/2015
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Provider Practice Location Address
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Address Line | 4818 W LONE MOUNTAIN RD
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City | LAS VEGAS
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State | NV
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Zip | 89130-2239
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Country | US
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Telephone | 702-655-9533
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Fax | 702-655-9565
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Provider Business Mailing Address
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Address Line | 4818 W LONE MOUNTAIN RD
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City | LAS VEGAS
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State | NV
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Zip | 89130-2239
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Country | US
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Telephone | 702-655-9533
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Fax | 702-655-9565
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Authorized Official
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Title or Position | PRESIDENT/ DOCTOR
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Name | DR. JOSHUA DAVID ETMAN
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Credential | DDS
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Telephone | 702-655-9533
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number | 6547
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License Number State | NV
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