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NPI Code Detail

MEDICARE: STAR SMILES CHILDRENS DENTISTRY

MEDICARE: STAR SMILES CHILDRENS DENTISTRY
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
1122300000XDentist4522TNV

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1518097153
Entity Type Code : Organization
Provider Name (Legal Business Name) : STAR SMILES CHILDRENS DENTISTRY
Provider Business Mailing Address
First Line : 4040 NORTH MARTIN LUTHER KING BLVD.
Second Line : SUITE B
City : NORTH LAS VEGAS
State : NV
Zip : 89032-6330
Country : US
Telephone Number : 702-639-3515
Fax Number : 702-639-3516
Provider Business Practice Location Address
First Line : 4040 NORTH MARTIN LUTHER KING BL
Second Line : SUITE B
City : NORTH LAS VEGAS
State : NV
Zip : 89032-3206
Country : US
Telephone Number : 702-639-3515
Fax Number : 702-639-3516
Authorized Official
Title or Position : DENTIST
Name : TIMOTHY A WILSON
Credential : DDS
Telephone Number : 702-639-3515
Provider Enumeration Date : 03/06/2007
Last Update Date : 04/04/2012

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Directions to “STAR SMILES CHILDRENS DENTISTRY ” Practice Location

Language Start Address Practice Location
These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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