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General NPI Number Information
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NPI Number | 1760511091
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Entity Type | Organization
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Legal Business Name | SOUTH EASTERN DENTAL
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Dates
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Enumeration Date | 03/04/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 8540 S EASTERN AVE STE 120
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City | LAS VEGAS
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State | NV
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Zip | 89123-2847
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Country | US
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Telephone | 702-967-2536
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Fax | 702-967-2538
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Provider Business Mailing Address
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Address Line | 8540 S EASTERN AVE STE 120
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City | LAS VEGAS
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State | NV
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Zip | 89123-2847
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Country | US
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Telephone | 702-967-2536
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Fax | 702-967-2538
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Authorized Official
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Title or Position | DENTIST
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Name | DR. TINA E. TIGERT
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Credential | D.D.S.
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Telephone | 702-967-2536
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 3329
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License Number State | NV
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