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NPI Code Detail

MEDICARE: ABRAZA DENTAL GROUP LLC

MEDICARE: ABRAZA DENTAL GROUP LLC
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
1122300000XDentist6743NV

General Provider Information

NPI Number : 1073963757
Entity Type Code : Organization
Provider Name (Legal Business Name) : ABRAZA DENTAL GROUP LLC
Provider Business Mailing Address
First Line : 5642 S EASTERN AVE
Second Line : SUITE B
City : LAS VEGAS
State : NV
Zip : 89119-2375
Country : US
Telephone Number : 702-456-0005
Fax Number :
Provider Business Practice Location Address
First Line : 5642 S EASTERN AVE
Second Line : SUITE B
City : LAS VEGAS
State : NV
Zip : 89119-2375
Country : US
Telephone Number : 702-456-0005
Fax Number :
Authorized Official
Title or Position : DDS
Name : WYATT STOTT DANNELS
Credential : DDS
Telephone Number : 702-456-0005
Provider Enumeration Date : 06/14/2016
Last Update Date : 06/15/2016

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