Provider Demographics
NPI:1417041146
Name:ELLSWORTH COX PEDIATRIC DENTISTRY LLC
Entity Type:Organization
Organization Name:ELLSWORTH COX PEDIATRIC DENTISTRY LLC
Other - Org Name:ANTHEM PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:B
Authorized Official - Last Name:MENDOZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-459-5437
Mailing Address - Street 1:2843 SAINT ROSE PKWY
Mailing Address - Street 2:#100
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-4813
Mailing Address - Country:US
Mailing Address - Phone:702-531-5437
Mailing Address - Fax:702-616-3565
Practice Address - Street 1:2843 SAINT ROSE PKWY
Practice Address - Street 2:#100
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-4813
Practice Address - Country:US
Practice Address - Phone:702-531-5437
Practice Address - Fax:702-616-3565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV43411223P0221X
NV36961223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV3696OtherSTATE LICENSE NUMBER
NV4341OtherSTATE LICENSE NUMBER