Provider Demographics
NPI:1871639831
Name:NEVADA TMJ INSTITUTE
Entity Type:Organization
Organization Name:NEVADA TMJ INSTITUTE
Other - Org Name:A BEAUTIFUL SMILE
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:ESCOTO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:702-259-4865
Mailing Address - Street 1:2650 LAKE SAHARA DR
Mailing Address - Street 2:120
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-3451
Mailing Address - Country:US
Mailing Address - Phone:702-259-4865
Mailing Address - Fax:702-243-7581
Practice Address - Street 1:2650 LAKE SAHARA DR
Practice Address - Street 2:120
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-3451
Practice Address - Country:US
Practice Address - Phone:702-259-4865
Practice Address - Fax:702-243-7581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV26791223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV=========OtherDENTIST