Provider Demographics
NPI:1083098032
Name:HENDERSON MODERN DENTISTRY
Entity Type:Organization
Organization Name:HENDERSON MODERN DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CODY
Authorized Official - Middle Name:
Authorized Official - Last Name:MUGLESTON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:702-464-3090
Mailing Address - Street 1:831 CORONADO CENTER DR
Mailing Address - Street 2:#22205
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-3991
Mailing Address - Country:US
Mailing Address - Phone:516-343-8731
Mailing Address - Fax:
Practice Address - Street 1:386 W LAKE MEAD PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89015-7417
Practice Address - Country:US
Practice Address - Phone:702-464-3090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-18
Last Update Date:2015-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV66501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty