Provider Demographics
NPI:1508282351
Name:MARICONDIA DENTAL PC
Entity Type:Organization
Organization Name:MARICONDIA DENTAL PC
Other - Org Name:AQ DENTURES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FRONT DESK
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-565-6000
Mailing Address - Street 1:349 W LAKE MEAD PKWY
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89015-7029
Mailing Address - Country:US
Mailing Address - Phone:702-565-6000
Mailing Address - Fax:702-565-0474
Practice Address - Street 1:349 W LAKE MEAD PKWY
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89015
Practice Address - Country:US
Practice Address - Phone:702-565-6000
Practice Address - Fax:702-565-0474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-17
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV40921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty