Provider Demographics
NPI:1790326056
Name:LUXE DENTAL LLC
Entity Type:Organization
Organization Name:LUXE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ANTOINETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:BROEDEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-374-1616
Mailing Address - Street 1:2001 RAMROD AVE APT 2711
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-2392
Mailing Address - Country:US
Mailing Address - Phone:702-374-1616
Mailing Address - Fax:
Practice Address - Street 1:2500 W SAHARA AVE STE 202
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-4367
Practice Address - Country:US
Practice Address - Phone:702-633-7500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-07
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty