MEDICARE: DRIVE INN DENTAL 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	:	1639777311
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DRIVE INN DENTAL LLC

Provider Business Mailing Address
First Line	:	4506 W CHARLESTON BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-1502
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4506 W CHARLESTON BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-1502
Country	:	US
Telephone Number	:	702-286-3721
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DOUGLAS KERN
Credential	:	DMD
Telephone Number	:	702-286-3721

Provider Enumeration Date	:	10/14/2020
Last Update Date	:	10/14/2020

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