Provider Demographics
NPI:1285017392
Name:NORTHERN NEVADA DENTAL SPECIALTIES GROUP, LLC
Entity Type:Organization
Organization Name:NORTHERN NEVADA DENTAL SPECIALTIES GROUP, LLC
Other - Org Name:LEGENDARY SMILES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:HELWIG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-336-1510
Mailing Address - Street 1:5220 NEIL RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-6505
Mailing Address - Country:US
Mailing Address - Phone:775-964-8762
Mailing Address - Fax:
Practice Address - Street 1:5220 NEIL RD
Practice Address - Street 2:SUITE 110
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-6505
Practice Address - Country:US
Practice Address - Phone:775-964-8762
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-07
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVS3-2441223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty