MEDICARE: HERRERA FAMILY DENTAL, PLLC

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	261QD0000X	Dental Clinic/Center	6786	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1699126094	OTHER	NV	NPI

General Provider Information

NPI Number	:	1285123851
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HERRERA FAMILY DENTAL, PLLC

Provider Business Mailing Address
First Line	:	1300 S LAMB BLVD STE 400
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-5540
Country	:	US
Telephone Number	:	702-274-1110
Fax Number	:	702-780-7669

Provider Business Practice Location Address
First Line	:	1300 S LAMB BLVD STE 400
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-5540
Country	:	US
Telephone Number	:	702-780-7660
Fax Number	:	702-780-7669

Authorized Official
Title or Position	:	OWNER
Name	:	DR. EVELYN HERRERA
Credential	:	DMD
Telephone Number	:	702-780-7660

Provider Enumeration Date	:	05/09/2018
Last Update Date	:	05/09/2018

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