MEDICARE: MODERN DENTAL SPECIALIST, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	1223P0106X	Oral and Maxillofacial Pathology Dentistry
2	1223P0300X	Periodontics
3	1223E0200X	Endodontics

General Provider Information

NPI Number	:	1962197897
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODERN DENTAL SPECIALIST, LLC

Provider Business Mailing Address
First Line	:	4618 MEADOWS LN
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89107-2956
Country	:	US
Telephone Number	:	702-623-3200
Fax Number	:

Provider Business Practice Location Address
First Line	:	6388 W SAHARA AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-3050
Country	:	US
Telephone Number	:	702-288-7200
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	BENNY KOHANTEB
Credential	:	DDS
Telephone Number	:	818-631-3368

Provider Enumeration Date	:	04/06/2023
Last Update Date	:	04/06/2023

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