MEDICARE: CALLAWAY-NELSON CENTENNIAL MODERN DENTISTRY, PC

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	122300000X	Dentist

General Provider Information

NPI Number	:	1982158150
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CALLAWAY-NELSON CENTENNIAL MODERN DENTISTRY, PC

Provider Business Mailing Address
First Line	:	17000 RED HILL AVE
Second Line	:
City	:	IRVINE
State	:	CA
Zip	:	92614-5626
Country	:	US
Telephone Number	:	714-845-8890
Fax Number	:	949-474-1495

Provider Business Practice Location Address
First Line	:	7910 W TROPICAL PKWY
Second Line	:	140
City	:	LAS VEGAS
State	:	NV
Zip	:	89149-4554
Country	:	US
Telephone Number	:	702-273-3676
Fax Number	:	702-430-6427

Authorized Official
Title or Position	:	OWNER
Name	:	DR. CARI A CALLAWAY-NELSON
Credential	:	DDS
Telephone Number	:	702-273-3676

Provider Enumeration Date	:	08/05/2016
Last Update Date	:	08/05/2016

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