MEDICARE: MOUTH FULL OF METAL 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
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	5697	NV

General Provider Information

NPI Number	:	1225316623
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUTH FULL OF METAL LLC

Provider Business Mailing Address
First Line	:	3648 AUCKLAND CASTLE ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89135-2816
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3648 AUCKLAND CASTLE ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89135-2816
Country	:	US
Telephone Number	:	702-482-8005
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	JAY DAVIS
Credential	:	D.M.D.
Telephone Number	:	702-482-8005

Provider Enumeration Date	:	08/02/2011
Last Update Date	:	08/02/2011

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