MEDICARE: GHAZAL LAS VEGAS MODERN SMILES DENTISTRY, PC

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

General Provider Information

NPI Number	:	1467928952
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GHAZAL LAS VEGAS MODERN SMILES DENTISTRY, PC

Provider Business Mailing Address
First Line	:	17000 RED HILL AVE
Second Line	:
City	:	IRVINE
State	:	CA
Zip	:	92614-5626
Country	:	US
Telephone Number	:	714-845-8500
Fax Number	:

Provider Business Practice Location Address
First Line	:	3119 N RAINBOW BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-4578
Country	:	US
Telephone Number	:	702-342-1604
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CAROLYN GHAZAL
Credential	:
Telephone Number	:	714-845-8500

Provider Enumeration Date	:	10/23/2018
Last Update Date	:	10/23/2018

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