MEDICARE: LUXE 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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1790326056
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LUXE DENTAL LLC

Provider Business Mailing Address
First Line	:	2001 RAMROD AVE APT 2711
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89014-2392
Country	:	US
Telephone Number	:	702-374-1616
Fax Number	:

Provider Business Practice Location Address
First Line	:	2500 W SAHARA AVE STE 202
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-4367
Country	:	US
Telephone Number	:	702-633-7500
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	ANTOINETTE BROEDEL
Credential	:
Telephone Number	:	702-374-1616

Provider Enumeration Date	:	10/07/2019
Last Update Date	:	10/07/2019

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