Provider Demographics
NPI:1629851159
Name:GHEISARI, MILAD
Entity Type:Individual
Prefix:
First Name:MILAD
Middle Name:
Last Name:GHEISARI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3850 W NEVSO DR UNIT 379
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-4072
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8380 W CHEYENNE AVE STE 103
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89129-2175
Practice Address - Country:US
Practice Address - Phone:702-843-0949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV78951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice