MEDICARE: DR. NICOLE LEILA MACKIE DDS, MS

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	122300000X	Dentist	DN18071	FL
2	122300000X	Dentist	DI024233	NJ
3	1223P0700X	Prosthodontics	055160-1	NY
4	1223P0700X	Prosthodontics	S543C	NV

General Provider Information

NPI Number	:	1205169034
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NICOLE LEILA MACKIE DDS, MS

Provider Business Mailing Address
First Line	:	8840 W RUSSELL RD STE 210
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89148-1355
Country	:	US
Telephone Number	:	702-463-1300
Fax Number	:	702-463-4633

Provider Business Practice Location Address
First Line	:	8840 W RUSSELL RD STE 210
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89148-1355
Country	:	US
Telephone Number	:	702-463-1300
Fax Number	:	702-463-4633

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

Provider Enumeration Date	:	09/11/2009
Last Update Date	:	09/14/2021

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