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General NPI Number Information
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NPI Number | 1457496077
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Entity Type | Organization
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Legal Business Name | THE DENTAL IMPLANT SOURCE
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Dates
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Enumeration Date | 02/21/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 8960 W CHEYENNE AVE UNIT 190
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City | LAS VEGAS
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State | NV
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Zip | 89129-8929
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Country | US
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Telephone | 702-367-4121
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Fax | 702-367-4021
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Provider Business Mailing Address
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Address Line | 8960 W CHEYENNE AVE UNIT 190
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City | LAS VEGAS
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State | NV
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Zip | 89129-8929
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Country | US
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Telephone | 702-367-4121
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Fax | 702-367-4021
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. LYLE SCOTT BROOKSBY
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Credential | DDS
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Telephone | 702-367-4121
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0700X
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Taxonomy Name | Prosthodontics
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License Number | 2543
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License Number State | NV
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