Provider Demographics
NPI:1114454097
Name:LEGENDARY SMILES ORTHODONTICS LLC
Entity Type:Organization
Organization Name:LEGENDARY SMILES ORTHODONTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NATE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROCKWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-336-1510
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:775-336-1510
Mailing Address - Fax:775-432-6001
Practice Address - Street 1:5220 NEIL RD.
Practice Address - Street 2:STE. 110
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502
Practice Address - Country:US
Practice Address - Phone:775-336-1510
Practice Address - Fax:775-336-1510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty