MEDICARE: CHILDREN'S DENTAL GROUP, INC.

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	1223P0221X	Pediatric Dentistry	3076	NV

General Provider Information

NPI Number	:	1881861037
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHILDREN'S DENTAL GROUP, INC.

Provider Business Mailing Address
First Line	:	8430 W LAKE MEAD BLVD
Second Line	:	SUITE 150
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-7672
Country	:	US
Telephone Number	:	702-220-9100
Fax Number	:	702-220-9104

Provider Business Practice Location Address
First Line	:	8430 W LAKE MEAD BLVD
Second Line	:	SUITE 150
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-7672
Country	:	US
Telephone Number	:	702-220-9100
Fax Number	:	702-220-9104

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ANDRE MICHAELIAN
Credential	:	DDS
Telephone Number	:	702-220-9100

Provider Enumeration Date	:	05/15/2008
Last Update Date	:	05/15/2008

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