MEDICARE: EASTERN HILL FAMILY DENTAL 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	5876	NV

General Provider Information

NPI Number	:	1417471509
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EASTERN HILL FAMILY DENTAL LLC

Provider Business Mailing Address
First Line	:	5905 S EASTERN AVE STE 112
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-3130
Country	:	US
Telephone Number	:	702-262-5693
Fax Number	:	702-507-6450

Provider Business Practice Location Address
First Line	:	5905 S EASTERN AVE STE 112
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-3130
Country	:	US
Telephone Number	:	702-262-5693
Fax Number	:	702-507-6450

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	SUE SHELL
Credential	:
Telephone Number	:	702-218-2713

Provider Enumeration Date	:	07/31/2017
Last Update Date	:	11/28/2017

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