MEDICARE: KIDS CHOICE PEDIATRIC DENTISTRY, 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	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1346992922
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDS CHOICE PEDIATRIC DENTISTRY, LLC

Provider Business Mailing Address
First Line	:	5680 W FLAMINGO RD STE A
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-2339
Country	:	US
Telephone Number	:	702-876-3222
Fax Number	:

Provider Business Practice Location Address
First Line	:	5680 W FLAMINGO RD STE A
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-2339
Country	:	US
Telephone Number	:	702-876-3222
Fax Number	:

Authorized Official
Title or Position	:	CONSULTING MANAGER
Name	:	STEVE IBEAWUCHI
Credential	:
Telephone Number	:	904-265-0765

Provider Enumeration Date	:	01/25/2022
Last Update Date	:	01/25/2022

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