MEDICARE: PURE DENTAL

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	4709	NV

General Provider Information

NPI Number	:	1508191420
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PURE DENTAL

Provider Business Mailing Address
First Line	:	4250 S RAINBOW BLVD
Second Line	:	#1004-1005
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-3159
Country	:	US
Telephone Number	:	702-456-4600
Fax Number	:	702-456-3600

Provider Business Practice Location Address
First Line	:	4250 S RAINBOW BLVD
Second Line	:	#1004-1005
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-3159
Country	:	US
Telephone Number	:	702-456-4600
Fax Number	:	702-456-3600

Authorized Official
Title or Position	:	OWNER
Name	:	TRANG NGUYEN
Credential	:
Telephone Number	:	702-456-4600

Provider Enumeration Date	:	10/09/2009
Last Update Date	:	10/09/2009

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