MEDICARE: EAST VALLEY DENTAL

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	4288	NV

General Provider Information

NPI Number	:	1871701425
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST VALLEY DENTAL

Provider Business Mailing Address
First Line	:	4230 E CHARLESTON BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-2397
Country	:	US
Telephone Number	:	702-459-7446
Fax Number	:	702-459-8078

Provider Business Practice Location Address
First Line	:	4230 E CHARLESTON BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-2397
Country	:	US
Telephone Number	:	702-459-7446
Fax Number	:	702-459-8078

Authorized Official
Title or Position	:	DENTIST OWNER
Name	:	DR. MICHAEL D WILSON
Credential	:	D.D.S
Telephone Number	:	702-459-7446

Provider Enumeration Date	:	05/18/2007
Last Update Date	:	08/22/2020

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Directions to “EAST VALLEY DENTAL ” Practice Location

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