Provider Demographics
NPI:1568778645
Name:RADIANT SMILES SERIES 5 LLC
Entity Type:Organization
Organization Name:RADIANT SMILES SERIES 5 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:C
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-312-8722
Mailing Address - Street 1:7469 W LAKE MEAD BLVD
Mailing Address - Street 2:STE 270
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-1030
Mailing Address - Country:US
Mailing Address - Phone:702-312-8722
Mailing Address - Fax:702-312-7779
Practice Address - Street 1:7469 W LAKE MEAD BLVD
Practice Address - Street 2:STE 270
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-1030
Practice Address - Country:US
Practice Address - Phone:702-312-8722
Practice Address - Fax:702-312-7779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-26
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV47251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty