Provider Demographics
NPI: | 1245433044 |
---|---|
Name: | SNELL-KILLAM, AIMEE NICOLE (DDS, MS) |
Entity Type: | Individual |
Prefix: | |
First Name: | AIMEE |
Middle Name: | NICOLE |
Last Name: | SNELL-KILLAM |
Suffix: | |
Gender: | F |
Credentials: | DDS, MS |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 1789 COLLEGE PKWY |
Mailing Address - Street 2: | STE 121 |
Mailing Address - City: | CARSON CITY |
Mailing Address - State: | NV |
Mailing Address - Zip Code: | 89706-7997 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 775-887-9453 |
Mailing Address - Fax: | 775-887-8915 |
Practice Address - Street 1: | 1789 COLLEGE PKWY |
Practice Address - Street 2: | STE 110 |
Practice Address - City: | CARSON CITY |
Practice Address - State: | NV |
Practice Address - Zip Code: | 89706-7997 |
Practice Address - Country: | US |
Practice Address - Phone: | 775-887-9453 |
Practice Address - Fax: | 775-887-8915 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2007-06-08 |
Last Update Date: | 2016-09-28 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MI | 2901019321 | 122300000X, 1223G0001X |
NV | 5794 | 1223P0221X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 1223P0221X | Dental Providers | Dentist | Pediatric Dentistry |
No | 122300000X | Dental Providers | Dentist | |
No | 1223G0001X | Dental Providers | Dentist | General Practice |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NV | 1245433044 | Medicaid |