Provider Demographics
NPI:1114183118
Name:PEDAITRIC DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:PEDAITRIC DENTAL ASSOCIATES
Other - Org Name:STAR SMILE CHILDREN DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:702-270-3047
Mailing Address - Street 1:7250 S DURANGO DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-2241
Mailing Address - Country:US
Mailing Address - Phone:702-270-3047
Mailing Address - Fax:702-614-0548
Practice Address - Street 1:7250 S DURANGO DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89113-2241
Practice Address - Country:US
Practice Address - Phone:702-270-3047
Practice Address - Fax:702-614-0548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-30
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty