Provider Demographics
NPI:1962831420
Name:NICHOLAS A MAFFEO DMD, PLLC
Entity Type:Organization
Organization Name:NICHOLAS A MAFFEO DMD, PLLC
Other - Org Name:LAS VEGAS DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:MAFFEO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:702-870-5165
Mailing Address - Street 1:2701 W CHARLESTON BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-2154
Mailing Address - Country:US
Mailing Address - Phone:702-870-5165
Mailing Address - Fax:
Practice Address - Street 1:2701 W CHARLESTON BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2154
Practice Address - Country:US
Practice Address - Phone:702-870-5165
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV5638,890,774,25131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty