Provider Demographics
NPI:1518097153
Name:STAR SMILES CHILDRENS DENTISTRY
Entity Type:Organization
Organization Name:STAR SMILES CHILDRENS DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:702-639-3515
Mailing Address - Street 1:4040 NORTH MARTIN LUTHER KING BLVD.
Mailing Address - Street 2:SUITE B
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032-6330
Mailing Address - Country:US
Mailing Address - Phone:702-639-3515
Mailing Address - Fax:702-639-3516
Practice Address - Street 1:4040 NORTH MARTIN LUTHER KING BL
Practice Address - Street 2:SUITE B
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-3206
Practice Address - Country:US
Practice Address - Phone:702-639-3515
Practice Address - Fax:702-639-3516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV4522T122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100506669Medicaid
NV100502976Medicaid