Provider Demographics
NPI:1598946261
Name:MARK I DEGEN DDS MD LTD
Entity Type:Organization
Organization Name:MARK I DEGEN DDS MD LTD
Other - Org Name:RED ROCK ORAL & MAXILLOFACIAL SURGERY CENTRE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:I
Authorized Official - Last Name:DEGEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD DDS
Authorized Official - Phone:7022-253-9090
Mailing Address - Street 1:4730 S. FORT APACHE ROAD
Mailing Address - Street 2:STE 390
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147
Mailing Address - Country:US
Mailing Address - Phone:702-253-9090
Mailing Address - Fax:702-253-9083
Practice Address - Street 1:4730 S. FORT APACHE ROAD
Practice Address - Street 2:STE 390
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89147
Practice Address - Country:US
Practice Address - Phone:702-253-9090
Practice Address - Fax:702-253-9083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-21
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV105351223S0112X, 261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV38085Medicare PIN
NV37968Medicare UPIN