MEDICARE: CARSON CITY PEDIATRIC 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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1730486747
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARSON CITY PEDIATRIC DENTISTRY, LLC

Provider Business Mailing Address
First Line	:	4530 S CARSON ST STE 5
Second Line	:
City	:	CARSON CITY
State	:	NV
Zip	:	89701-6914
Country	:	US
Telephone Number	:	775-461-3800
Fax Number	:	775-461-3801

Provider Business Practice Location Address
First Line	:	4530 S CARSON ST STE 5
Second Line	:
City	:	CARSON CITY
State	:	NV
Zip	:	89701-6914
Country	:	US
Telephone Number	:	702-308-6556
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. KEVIN OLSON
Credential	:	D.M.D.
Telephone Number	:	775-461-3800

Provider Enumeration Date	:	02/28/2011
Last Update Date	:	09/16/2011

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