Provider Demographics
NPI:1174686034
Name:BLACK MOUNTAIN DENTAL
Entity Type:Organization
Organization Name:BLACK MOUNTAIN DENTAL
Other - Org Name:BLACK MOUNTAIN DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:GARTH
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:702-699-5551
Mailing Address - Street 1:270 E HORIZON DR
Mailing Address - Street 2:SUITE 106
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89015-8036
Mailing Address - Country:US
Mailing Address - Phone:702-699-5551
Mailing Address - Fax:
Practice Address - Street 1:270 E HORIZON DR
Practice Address - Street 2:SUITE 106
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89015-8036
Practice Address - Country:US
Practice Address - Phone:702-699-5551
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV32081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty