MEDICARE: IMPLANTS DENTURES & DENTAL, INC

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1144528795
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMPLANTS DENTURES & DENTAL, INC

Provider Business Mailing Address
First Line	:	2605 S DECATUR BLVD
Second Line	:	STE 116
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-8591
Country	:	US
Telephone Number	:	702-876-2525
Fax Number	:	602-297-6870

Provider Business Practice Location Address
First Line	:	2605 S DECATUR BLVD
Second Line	:	STE 116
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-8591
Country	:	US
Telephone Number	:	702-876-2525
Fax Number	:	602-297-6870

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. BRANDON M DHAENENS
Credential	:
Telephone Number	:	702-876-2525

Provider Enumeration Date	:	03/07/2011
Last Update Date	:	03/07/2011

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