Provider Demographics
NPI:1326069634
Name:CANSDALE, JERROLD P (DDS)
Entity Type:Individual
Prefix:
First Name:JERROLD
Middle Name:P
Last Name:CANSDALE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1802 N CARSON ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89701-1265
Mailing Address - Country:US
Mailing Address - Phone:775-888-6610
Mailing Address - Fax:775-887-7046
Practice Address - Street 1:2212 S EASTERN AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-4124
Practice Address - Country:US
Practice Address - Phone:702-735-9334
Practice Address - Fax:702-735-9335
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2050122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1326069634Medicaid
NV2050OtherNV DENTAL LICENSE