=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619121159
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DURANGO ORTHODONTICS, LLLP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/11/2008
-----------------------------------------------------
Last Update Date | 11/11/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6002 S DURANGO DR SUITE 100
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89113-1785
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-750-2400
-----------------------------------------------------
Fax | 702-750-2401
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 400760
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89140-0760
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-750-2400
-----------------------------------------------------
Fax | 702-750-2401
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | DR. JAMES K MAH
-----------------------------------------------------
Credential | DDS, MSC, MRCD(C), D
-----------------------------------------------------
Telephone | 702-750-2400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | S3-138
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | S3-166
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------