MEDICARE: GUSSOW DENTAL CARE PROF CORP

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	332BC3200X	Customized Equipment (DME)
2	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1174398416
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GUSSOW DENTAL CARE PROF CORP

Provider Business Mailing Address
First Line	:	10420 S DECATUR BLVD STE 110
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89141-8718
Country	:	US
Telephone Number	:	702-371-0221
Fax Number	:

Provider Business Practice Location Address
First Line	:	4343 N RANCHO DR STE 131
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89130-3422
Country	:	US
Telephone Number	:	702-395-7200
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	JONATHAN WELCH
Credential	:	DMD
Telephone Number	:	702-371-0221

Provider Enumeration Date	:	11/16/2023
Last Update Date	:	02/14/2025

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