Provider Demographics
NPI:1043725039
Name:NORTHERN NEVADA DENTAL SPECIALTIES GROUP, LLC
Entity Type:Organization
Organization Name:NORTHERN NEVADA DENTAL SPECIALTIES GROUP, LLC
Other - Org Name:MY KIDS SMILE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ALETA
Authorized Official - Middle Name:VALERIE
Authorized Official - Last Name:BEUTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-409-4614
Mailing Address - Street 1:3605 GRANT DR
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-5301
Mailing Address - Country:US
Mailing Address - Phone:775-409-4614
Mailing Address - Fax:775-376-9075
Practice Address - Street 1:5030 LAS BRISAS BLVD STE B-3
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89523-6239
Practice Address - Country:US
Practice Address - Phone:775-852-6164
Practice Address - Fax:775-284-7352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-12
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1223P0221XOtherPEDIATRIC DENTISTRY