MEDICARE: VEGAS PEDIATRIC PARTNERS

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

General Provider Information

NPI Number	:	1942945340
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VEGAS PEDIATRIC PARTNERS

Provider Business Mailing Address
First Line	:	5642 S EASTERN AVE STE F
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-2310
Country	:	US
Telephone Number	:	702-508-0755
Fax Number	:	702-659-7116

Provider Business Practice Location Address
First Line	:	5642 S EASTERN AVE STE F
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-2310
Country	:	US
Telephone Number	:	702-508-0755
Fax Number	:	702-659-7116

Authorized Official
Title or Position	:	REGIONAL OFFICE MANAGER
Name	:	DIANA J CAZZALY
Credential	:
Telephone Number	:	702-456-0005

Provider Enumeration Date	:	04/29/2022
Last Update Date	:	04/29/2022

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