MEDICARE: NORTH LAS VEGAS DENTAL GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	4555	NV

General Provider Information

NPI Number	:	1023326162
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH LAS VEGAS DENTAL GROUP

Provider Business Mailing Address
First Line	:	1703 CIVIC CENTER DR STE 5
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89030-7273
Country	:	US
Telephone Number	:	702-452-5751
Fax Number	:	702-868-5755

Provider Business Practice Location Address
First Line	:	1703 CIVIC CENTER DR STE 5
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89030-7273
Country	:	US
Telephone Number	:	702-452-5751
Fax Number	:	702-868-5755

Authorized Official
Title or Position	:	PRESIDENT
Name	:	THOMAS TRINH
Credential	:
Telephone Number	:	702-452-5751

Provider Enumeration Date	:	09/23/2010
Last Update Date	:	09/23/2010

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