MEDICARE: DENTALVILLE

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	3580	NV

General Provider Information

NPI Number	:	1871772368
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTALVILLE

Provider Business Mailing Address
First Line	:	945 S RAINBOW BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89145-6230
Country	:	US
Telephone Number	:	702-258-8216
Fax Number	:	702-870-0974

Provider Business Practice Location Address
First Line	:	1180 S BEVERLY DR STE 401
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90035-1156
Country	:	US
Telephone Number	:	310-804-1972
Fax Number	:

Authorized Official
Title or Position	:	REGIONAL MANAGER
Name	:	MARINA KOZYR
Credential	:
Telephone Number	:	310-804-1972

Provider Enumeration Date	:	10/31/2007
Last Update Date	:	10/31/2007

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Directions to “DENTALVILLE ” Practice Location

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