Provider Demographics
NPI:1558620823
Name:MUGLESTON HENDERSON MODERN DENTISTRY, PC
Entity Type:Organization
Organization Name:MUGLESTON HENDERSON MODERN DENTISTRY, PC
Other - Org Name:HENDERSON MODERN DENTISTRY AND ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DDS-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CODY
Authorized Official - Middle Name:P
Authorized Official - Last Name:MUGLESTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-464-3090
Mailing Address - Street 1:17000 RED HILL AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-5626
Mailing Address - Country:US
Mailing Address - Phone:714-845-8890
Mailing Address - Fax:949-474-1495
Practice Address - Street 1:366 W LAKE MEAD PKWY STE 100
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89015-7287
Practice Address - Country:US
Practice Address - Phone:702-464-3090
Practice Address - Fax:702-464-3158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-08
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV49081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty