Provider Demographics
NPI:1225058746
Name:JAMES R DETTLING MD
Entity Type:Organization
Organization Name:JAMES R DETTLING MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:SVIDERSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-877-6781
Mailing Address - Street 1:801 S RANCHO DR STE F2
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-3814
Mailing Address - Country:US
Mailing Address - Phone:702-877-6781
Mailing Address - Fax:
Practice Address - Street 1:801 S RANCHO DR STE F2
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-3814
Practice Address - Country:US
Practice Address - Phone:702-877-6781
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV8925174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty