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General NPI Number Information
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NPI Number | 1558897884
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Entity Type | Organization
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Legal Business Name | MJD, LLC
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Dates
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Enumeration Date | 05/05/2017
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Last Update Date | 05/05/2017
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Provider Practice Location Address
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Address Line | 1701 W CHARLESTON BLVD 520
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City | LAS VEGAS
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State | NV
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Zip | 89102-2325
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Country | US
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Telephone | 702-750-9444
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Fax | 702-750-9442
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Provider Business Mailing Address
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Address Line | 1701 W CHARLESTON BLVD 520
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City | LAS VEGAS
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State | NV
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Zip | 89102-2325
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Country | US
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Telephone | 702-750-9444
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Fax | 702-750-9442
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Authorized Official
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Title or Position | OWNER
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Name | MICHEL DACCACHE
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Credential | DDS
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Telephone | 702-750-9444
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | S2-112C
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License Number State | NV
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