Provider Demographics
NPI:1679841258
Name:RAINCHARLIE DENTAL, LLC
Entity Type:Organization
Organization Name:RAINCHARLIE DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOHANTEB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-435-5015
Mailing Address - Street 1:526 S TONOPAH DR
Mailing Address - Street 2:#200
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4043
Mailing Address - Country:US
Mailing Address - Phone:402-435-5015
Mailing Address - Fax:702-366-1483
Practice Address - Street 1:945 S RAINBOW BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89145-6230
Practice Address - Country:US
Practice Address - Phone:702-331-8585
Practice Address - Fax:702-382-4469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-09
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV20111452524261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental