MEDICARE: DR. DEBORHA LYNN STATEN D.M.D.

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	1223G0001X	General Practice Dentistry	6292	NV

General Provider Information

NPI Number	:	1104175272
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DEBORHA LYNN STATEN D.M.D.

Provider Business Mailing Address
First Line	:	680 PROSSER CREEK PL
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89002-0953
Country	:	US
Telephone Number	:	702-595-6505
Fax Number	:

Provider Business Practice Location Address
First Line	:	5475 S FORT APACHE RD STE 100
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89148-6410
Country	:	US
Telephone Number	:	702-736-7979
Fax Number	:	702-736-5851

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/05/2012
Last Update Date	:	10/20/2020

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