MEDICARE: DR. PHILLIP RUSSELL DEVORE D.D.S.

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	4285	NV

General Provider Information

NPI Number	:	1992765366
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PHILLIP RUSSELL DEVORE D.D.S.

Provider Business Mailing Address
First Line	:	1001 SHADOW LANE MS 7413
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89106
Country	:	US
Telephone Number	:	702-774-8000
Fax Number	:	702-774-2812

Provider Business Practice Location Address
First Line	:	1700 W CHARLESTON BLDG D
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89102
Country	:	US
Telephone Number	:	702-774-8000
Fax Number	:	702-774-2812

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/28/2006
Last Update Date	:	02/05/2015

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