MEDICARE: SMILE CARE SPECIALTY SOUTHERN NEVADA 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	1223E0200X	Endodontics	S7-83	NV

General Provider Information

NPI Number	:	1609315472
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMILE CARE SPECIALTY SOUTHERN NEVADA LLC

Provider Business Mailing Address
First Line	:	6386 W SAHARA AVE
Second Line	:	# 6388
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-3050
Country	:	US
Telephone Number	:	702-228-7200
Fax Number	:	702-889-7200

Provider Business Practice Location Address
First Line	:	6386 W SAHARA AVE
Second Line	:	# 6388
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-3050
Country	:	US
Telephone Number	:	702-228-7200
Fax Number	:	702-889-7200

Authorized Official
Title or Position	:	OWNER
Name	:	BRAD RADLOSKY
Credential	:
Telephone Number	:	702-228-7200

Provider Enumeration Date	:	02/14/2017
Last Update Date	:	02/14/2017

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