MEDICARE: POUYA MOMTAZ DMD 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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	S3-304	NV

General Provider Information

NPI Number	:	1477067973
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POUYA MOMTAZ DMD PLLC

Provider Business Mailing Address
First Line	:	4045 S EASTERN AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-5101
Country	:	US
Telephone Number	:	702-892-9878
Fax Number	:

Provider Business Practice Location Address
First Line	:	4045 S EASTERN AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-5101
Country	:	US
Telephone Number	:	702-892-9878
Fax Number	:

Authorized Official
Title or Position	:	ORTHODONTIST
Name	:	DR. POUYA MOMTAZ
Credential	:	DMD, MS
Telephone Number	:	702-546-9936

Provider Enumeration Date	:	11/21/2017
Last Update Date	:	05/07/2020

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