MEDICARE: DR. MARLOWE ANTHONY SAN JUAN RILLERA DMD

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	122300000X	Dentist	30249	TX
2	1223G0001X	General Practice Dentistry	7352	NV

General Provider Information

NPI Number	:	1417366261
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARLOWE ANTHONY SAN JUAN RILLERA DMD

Provider Business Mailing Address
First Line	:	2625 S RAINBOW BLVD STE D103
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-5181
Country	:	US
Telephone Number	:	702-365-1743
Fax Number	:

Provider Business Practice Location Address
First Line	:	2625 S RAINBOW BLVD STE D103
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-5181
Country	:	US
Telephone Number	:	702-365-1743
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/06/2014
Last Update Date	:	07/07/2020

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