Provider Demographics
NPI:1417471509
Name:EASTERN HILL FAMILY DENTAL LLC
Entity Type:Organization
Organization Name:EASTERN HILL FAMILY DENTAL LLC
Other - Org Name:EASTERN HILLS FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:SUE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-218-2713
Mailing Address - Street 1:5905 S EASTERN AVE STE 112
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-3130
Mailing Address - Country:US
Mailing Address - Phone:702-262-5693
Mailing Address - Fax:702-507-6450
Practice Address - Street 1:5905 S EASTERN AVE STE 112
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-3130
Practice Address - Country:US
Practice Address - Phone:702-262-5693
Practice Address - Fax:702-507-6450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-31
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV58761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty