MEDICARE: DESERT DENTAL ASSOCIATES IV, 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	:	1861720864
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DESERT DENTAL ASSOCIATES IV, LLC

Provider Business Mailing Address
First Line	:	4358 W. CHYENNE AVE.
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032
Country	:	US
Telephone Number	:	702-953-2239
Fax Number	:	702-990-0304

Provider Business Practice Location Address
First Line	:	4358 W. CHYENNE AVE.
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032
Country	:	US
Telephone Number	:	702-953-2239
Fax Number	:	702-990-0304

Authorized Official
Title or Position	:	OWNER- DENTIST
Name	:	MATTHEW WELEBIR
Credential	:	DDS
Telephone Number	:	702-953-2239

Provider Enumeration Date	:	12/02/2009
Last Update Date	:	12/02/2009

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