Provider Demographics
NPI:1558897884
Name:MJD, LLC
Entity Type:Organization
Organization Name:MJD, LLC
Other - Org Name:NEVADA OMS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DACCACHE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:702-750-9444
Mailing Address - Street 1:1701 W CHARLESTON BLVD
Mailing Address - Street 2:520
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-2325
Mailing Address - Country:US
Mailing Address - Phone:702-750-9444
Mailing Address - Fax:702-750-9442
Practice Address - Street 1:1701 W CHARLESTON BLVD
Practice Address - Street 2:520
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2325
Practice Address - Country:US
Practice Address - Phone:702-750-9444
Practice Address - Fax:702-750-9442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-05
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVS2-112C1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty