Provider Demographics
NPI:1154637890
Name:RADIANT SMILES SERIES 4 LLC
Entity Type:Organization
Organization Name:RADIANT SMILES SERIES 4 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:FABIAN
Authorized Official - Last Name:CORDERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-368-0911
Mailing Address - Street 1:4510 S EASTERN AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-6118
Mailing Address - Country:US
Mailing Address - Phone:702-368-0911
Mailing Address - Fax:702-734-6884
Practice Address - Street 1:4510 S EASTERN AVE STE 2
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-6118
Practice Address - Country:US
Practice Address - Phone:702-368-0911
Practice Address - Fax:702-734-6884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-19
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV47251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty