MEDICARE: ADA NEVADA DENTAL 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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1942963103
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADA NEVADA DENTAL LLC

Provider Business Mailing Address
First Line	:	2085 VILLAGE CENTER CIR STE 140
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89134-6263
Country	:	US
Telephone Number	:	702-766-5835
Fax Number	:

Provider Business Practice Location Address
First Line	:	2085 VILLAGE CENTER CIR STE 140
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89134-6263
Country	:	US
Telephone Number	:	702-766-5835
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	GREGORY WALTER GREENWOOD
Credential	:	DMD,PHARMD,MACSD
Telephone Number	:	504-952-0344

Provider Enumeration Date	:	10/14/2021
Last Update Date	:	10/14/2021

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