MEDICARE: SHADOW CREEK CHILDREN'S DENTISTRY AND ORTHODONTICS GENERAL PARTNERSHIP

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry
2	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1063309755
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHADOW CREEK CHILDREN'S DENTISTRY AND ORTHODONTICS GENERAL PARTNERSHIP

Provider Business Mailing Address
First Line	:	3196 S MARYLAND PKWY STE 307
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89109-2314
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3410 E CENTENNIAL PKWY STE 110
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89081-5627
Country	:	US
Telephone Number	:	702-701-2563
Fax Number	:

Authorized Official
Title or Position	:	PARTNER
Name	:	RYAN JOLLEY
Credential	:
Telephone Number	:	702-701-2563

Provider Enumeration Date	:	06/23/2025
Last Update Date	:	06/23/2025

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