MEDICARE: SIMISTER PREMIER ORTHODONTICS

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	S3153

General Provider Information

NPI Number	:	1063606580
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SIMISTER PREMIER ORTHODONTICS

Provider Business Mailing Address
First Line	:	4306 S EASTERN AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-6016
Country	:	US
Telephone Number	:	702-735-4169
Fax Number	:	702-735-8697

Provider Business Practice Location Address
First Line	:	2430 E HARMON AVE
Second Line	:	SUITE 3
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-5338
Country	:	US
Telephone Number	:	702-735-4169
Fax Number	:	702-735-8697

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DOUGLAS K SIMISTER
Credential	:	D.D.S.
Telephone Number	:	702-735-4169

Provider Enumeration Date	:	08/28/2007
Last Update Date	:	02/19/2014

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