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NPI Code Detail

MEDICARE: TENDER DENTAL BONANAZA, LLC

MEDICARE: TENDER DENTAL BONANAZA, 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
11223G0001XGeneral Practice Dentistry6883NV

General Provider Information

NPI Number : 1124556741
Entity Type Code : Organization
Provider Name (Legal Business Name) : TENDER DENTAL BONANAZA, LLC
Provider Business Mailing Address
First Line : 301 COMMONS PARK S UNIT 618
Second Line :
City : STAMFORD
State : CT
Zip : 06902-7088
Country : US
Telephone Number : 860-491-6972
Fax Number :
Provider Business Practice Location Address
First Line : 5001 E BONANZA RD STE 160
Second Line :
City : LAS VEGAS
State : NV
Zip : 89110-3560
Country : US
Telephone Number : 860-325-0022
Fax Number :
Authorized Official
Title or Position : PRESIDENT
Name : JONG UM
Credential : DDS
Telephone Number : 860-325-0022
Provider Enumeration Date : 05/25/2017
Last Update Date : 05/25/2017

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Directions to “TENDER DENTAL BONANAZA, LLC ” Practice Location

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