MEDICARE: AXIOM DENTISTRY, 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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)

General Provider Information

NPI Number	:	1922657808
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AXIOM DENTISTRY, LLC

Provider Business Mailing Address
First Line	:	4358 W CHEYENNE AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-2484
Country	:	US
Telephone Number	:	714-578-6591
Fax Number	:

Provider Business Practice Location Address
First Line	:	410 S RAMPART BLVD STE 360
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89145-5730
Country	:	US
Telephone Number	:	702-228-2218
Fax Number	:	702-228-7411

Authorized Official
Title or Position	:	SUPERVISOR
Name	:	BEATRIZ HERNANDEZ
Credential	:
Telephone Number	:	714-578-6591

Provider Enumeration Date	:	09/04/2019
Last Update Date	:	09/04/2019

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