MEDICARE: RADIANT SMILES SERIES 5 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	1223G0001X	General Practice Dentistry	4725	NV

General Provider Information

NPI Number	:	1568778645
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RADIANT SMILES SERIES 5 LLC

Provider Business Mailing Address
First Line	:	7469 W LAKE MEAD BLVD
Second Line	:	STE 270
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-1030
Country	:	US
Telephone Number	:	702-312-8722
Fax Number	:	702-312-7779

Provider Business Practice Location Address
First Line	:	7469 W LAKE MEAD BLVD
Second Line	:	STE 270
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-1030
Country	:	US
Telephone Number	:	702-312-8722
Fax Number	:	702-312-7779

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. DAVID C GONZALEZ
Credential	:
Telephone Number	:	702-312-8722

Provider Enumeration Date	:	08/26/2010
Last Update Date	:	08/26/2010

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