Provider Demographics
NPI:1518523729
Name:AQUA DENTAL GROUP LLC
Entity Type:Organization
Organization Name:AQUA DENTAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEILA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHOSSOOSI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:702-522-9192
Mailing Address - Street 1:2285 E FLAMINGO RD STE 101
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-5114
Mailing Address - Country:US
Mailing Address - Phone:702-522-9192
Mailing Address - Fax:888-299-5749
Practice Address - Street 1:2500 WIGWAM PKWY STE 110
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074-7113
Practice Address - Country:US
Practice Address - Phone:702-522-9192
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-13
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental