MEDICARE: LONE MOUNTAIN 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	2791	NV

General Provider Information

NPI Number	:	1649493164
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LONE MOUNTAIN DENTAL, LLC

Provider Business Mailing Address
First Line	:	4818 W LONE MOUNTAIN RD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89130-2239
Country	:	US
Telephone Number	:	702-655-9533
Fax Number	:	702-655-9565

Provider Business Practice Location Address
First Line	:	4818 W LONE MOUNTAIN RD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89130-2239
Country	:	US
Telephone Number	:	702-655-9533
Fax Number	:	702-655-9565

Authorized Official
Title or Position	:	OWNER
Name	:	BARRY KENNEDY
Credential	:	DDS
Telephone Number	:	702-655-9533

Provider Enumeration Date	:	04/11/2007
Last Update Date	:	08/22/2020

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