MEDICARE: THE DENTAL DIFFERENCE 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	1223G0001X	General Practice Dentistry
2	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1225513732
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE DENTAL DIFFERENCE LLC

Provider Business Mailing Address
First Line	:	1264 S NELLIS BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-5782
Country	:	US
Telephone Number	:	702-998-7400
Fax Number	:	702-944-7970

Provider Business Practice Location Address
First Line	:	1264 S NELLIS BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-5782
Country	:	US
Telephone Number	:	702-998-7400
Fax Number	:	702-944-7970

Authorized Official
Title or Position	:	MANAGER
Name	:	MISS MICHELE EDWARDS
Credential	:
Telephone Number	:	702-998-7400

Provider Enumeration Date	:	10/01/2018
Last Update Date	:	10/01/2018

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Directions to “THE DENTAL DIFFERENCE LLC ” Practice Location

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