Provider Demographics
NPI:1093919458
Name:MOSAIC DENTAL, PROF. CORP.
Entity Type:Organization
Organization Name:MOSAIC DENTAL, PROF. CORP.
Other - Org Name:MOSAIC DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:HAI
Authorized Official - Middle Name:Q
Authorized Official - Last Name:XA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:702-456-0034
Mailing Address - Street 1:9690 W. TROPICANA AVE.
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147
Mailing Address - Country:US
Mailing Address - Phone:702-433-8400
Mailing Address - Fax:
Practice Address - Street 1:STAR BRITE DENTAL
Practice Address - Street 2:893 S. RAINBOW BLVD.
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89145
Practice Address - Country:US
Practice Address - Phone:702-456-0034
Practice Address - Fax:702-856-0035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3780305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization