Provider Demographics
NPI:1457496077
Name:THE DENTAL IMPLANT SOURCE
Entity Type:Organization
Organization Name:THE DENTAL IMPLANT SOURCE
Other - Org Name:CHEYENNE ADVANCED DENTAL ARTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LYLE
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:BROOKSBY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:702-367-4121
Mailing Address - Street 1:8960 W CHEYENNE AVE UNIT 190
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89129-8929
Mailing Address - Country:US
Mailing Address - Phone:702-367-4121
Mailing Address - Fax:702-367-4021
Practice Address - Street 1:8960 W CHEYENNE AVE UNIT 190
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89129-8929
Practice Address - Country:US
Practice Address - Phone:702-367-4121
Practice Address - Fax:702-367-4021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV25431223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVT09072Medicare UPIN