Provider Demographics
NPI:1336310309
Name:LEBROKE, RONALD L (DMD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:L
Last Name:LEBROKE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 S TONOPAH DR
Mailing Address - Street 2:SUITE #200
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4043
Mailing Address - Country:US
Mailing Address - Phone:702-291-2031
Mailing Address - Fax:702-366-1483
Practice Address - Street 1:4720 BLUE DIAMOND RD
Practice Address - Street 2:#100
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89139-7661
Practice Address - Country:US
Practice Address - Phone:702-855-0050
Practice Address - Fax:702-629-2410
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-18
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV56061223G0001X
CA570691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1336310309Medicaid