MEDICARE: AMERITINA DENTAL EASTERN 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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1477183101
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMERITINA DENTAL EASTERN LLC

Provider Business Mailing Address
First Line	:	2810 BELLINI DR
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89052-3118
Country	:	US
Telephone Number	:	646-592-5597
Fax Number	:	702-722-2277

Provider Business Practice Location Address
First Line	:	581 N EASTERN AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89101-3422
Country	:	US
Telephone Number	:	702-444-7810
Fax Number	:	702-445-6299

Authorized Official
Title or Position	:	CEO
Name	:	ARASH BAKHAJ
Credential	:	DDS
Telephone Number	:	646-592-5597

Provider Enumeration Date	:	01/22/2020
Last Update Date	:	01/22/2020

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