MEDICARE: NEA DENTISTRY 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	122300000X	Dentist

General Provider Information

NPI Number	:	1629573266
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEA DENTISTRY LLC

Provider Business Mailing Address
First Line	:	2085 VILLAGE CENTER CIR STE 140
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89134-6263
Country	:	US
Telephone Number	:	702-256-6001
Fax Number	:

Provider Business Practice Location Address
First Line	:	2085 VILLAGE CENTER CIR STE 140
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89134-6263
Country	:	US
Telephone Number	:	860-491-6972
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	DR. PETER STEPHEN BONIFATTO
Credential	:
Telephone Number	:	702-256-6001

Provider Enumeration Date	:	03/27/2018
Last Update Date	:	02/24/2022

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Directions to “NEA DENTISTRY LLC ” Practice Location

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