MEDICARE: REBEL ORTHO 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

General Provider Information

NPI Number	:	1255161097
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REBEL ORTHO LLC

Provider Business Mailing Address
First Line	:	1306 W CRAIG RD STE H
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-0215
Country	:	US
Telephone Number	:	702-633-4333
Fax Number	:

Provider Business Practice Location Address
First Line	:	1306 W CRAIG RD STE H
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-0215
Country	:	US
Telephone Number	:	702-633-4333
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ZACHARY SOARD
Credential	:	DMD
Telephone Number	:	702-742-5824

Provider Enumeration Date	:	08/06/2024
Last Update Date	:	08/06/2024

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Directions to “REBEL ORTHO LLC ” Practice Location

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