Provider Demographics
NPI: | 1528365897 |
---|---|
Name: | RAINBOW DENTAL, LLC |
Entity Type: | Organization |
Organization Name: | RAINBOW DENTAL, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | BENNY |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | KOHANTEB |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 702-435-5015 |
Mailing Address - Street 1: | 526 S TONOPAH DR |
Mailing Address - Street 2: | SUITE 200 |
Mailing Address - City: | LAS VEGAS |
Mailing Address - State: | NV |
Mailing Address - Zip Code: | 89106-4043 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 702-435-5015 |
Mailing Address - Fax: | 702-366-1483 |
Practice Address - Street 1: | 7320 S RAINBOW BLVD |
Practice Address - Street 2: | SUITE 103 |
Practice Address - City: | LAS VEGAS |
Practice Address - State: | NV |
Practice Address - Zip Code: | 89139-0406 |
Practice Address - Country: | US |
Practice Address - Phone: | 702-435-5015 |
Practice Address - Fax: | 702-366-1483 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2011-02-22 |
Last Update Date: | 2011-02-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NV | 4509 | 1223G0001X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223G0001X | Dental Providers | Dentist | General Practice | Group - Single Specialty |