1487884268 NPI number — DESERT DENTAL

Table of content: (NPI 1487884268)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487884268 NPI number — DESERT DENTAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DESERT DENTAL
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ILYA BENJAMIN
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487884268
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
55 S. VALLE VERDE DR.
Provider Second Line Business Mailing Address:
SUITE #250
Provider Business Mailing Address City Name:
HENDERSON
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89012
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-260-1890
Provider Business Mailing Address Fax Number:
702-260-7936

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
55 S VALLE VERDE DR
Provider Second Line Business Practice Location Address:
SUITE #250
Provider Business Practice Location Address City Name:
HENDERSON
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89012-3433
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-260-1890
Provider Business Practice Location Address Fax Number:
702-260-7936
Provider Enumeration Date:
07/15/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BENJAMIN
Authorized Official First Name:
ILYA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/DOCTOR
Authorized Official Telephone Number:
702-260-1890

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  5852 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1326027095 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




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