Provider Demographics
NPI:1134662679
Name:CCPD LLC
Entity Type:Organization
Organization Name:CCPD LLC
Other - Org Name:CARSON CITY PEDIATRIC DENTISTRY
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:775-461-3800
Mailing Address - Street 1:4530 S CARSON ST STE 5
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89701-6914
Mailing Address - Country:US
Mailing Address - Phone:775-461-3800
Mailing Address - Fax:775-461-3801
Practice Address - Street 1:4530 S CARSON ST STE 5
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89701-6914
Practice Address - Country:US
Practice Address - Phone:775-461-3800
Practice Address - Fax:775-461-3801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-01
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVS6-1091223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty