MEDICARE: NEVADA TMJ INSTITUTE

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	2679	NV

General Provider Information

NPI Number	:	1871639831
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEVADA TMJ INSTITUTE

Provider Business Mailing Address
First Line	:	2650 LAKE SAHARA DR
Second Line	:	120
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-3451
Country	:	US
Telephone Number	:	702-259-4865
Fax Number	:	702-243-7581

Provider Business Practice Location Address
First Line	:	2650 LAKE SAHARA DR
Second Line	:	120
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-3451
Country	:	US
Telephone Number	:	702-259-4865
Fax Number	:	702-243-7581

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. MARK JOHN ESCOTO
Credential	:	D.D.S.
Telephone Number	:	702-259-4865

Provider Enumeration Date	:	01/29/2007
Last Update Date	:	08/02/2013

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