Provider Demographics
NPI:1760795256
Name:DILETTANTE INC.
Entity Type:Organization
Organization Name:DILETTANTE INC.
Other - Org Name:AVALON DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:K
Authorized Official - Last Name:PROPSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-638-1005
Mailing Address - Street 1:5465 SIMMONS ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-9000
Mailing Address - Country:US
Mailing Address - Phone:702-638-1005
Mailing Address - Fax:702-638-1071
Practice Address - Street 1:5465 SIMMONS ST
Practice Address - Street 2:SUITE 4
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-9000
Practice Address - Country:US
Practice Address - Phone:702-638-1005
Practice Address - Fax:702-638-1071
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RANDY HONG
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-07-26
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV4348122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100510098Medicaid