=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528260163
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WATANABE RANCH PLAZA DENTAL GROUP, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2007
-----------------------------------------------------
Last Update Date | 04/13/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9771 SE AVE SUITE 100
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-616-9655
-----------------------------------------------------
Fax | 702-837-1302
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 920050
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75392-0050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-845-8890
-----------------------------------------------------
Fax | 949-474-1495
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER DOCTOR
-----------------------------------------------------
Name | DR. PATRICK ANGHEL
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 702-616-9655
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------