Provider Demographics
NPI:1073995213
Name:NORTHERN NEVADA DENTAL SPECIALTY GROUP
Entity Type:Organization
Organization Name:NORTHERN NEVADA DENTAL SPECIALTY GROUP
Other - Org Name:MY KID'S SMILE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:CHANNING
Authorized Official - Last Name:CHRISTIANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-848-3005
Mailing Address - Street 1:10645 DOUBLE R BLVD
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89521-8920
Mailing Address - Country:US
Mailing Address - Phone:775-852-6164
Mailing Address - Fax:
Practice Address - Street 1:3150 VISTA BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89436-6712
Practice Address - Country:US
Practice Address - Phone:775-852-6164
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-24
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV4489122300000X
NV36-1171223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty