Provider Demographics
NPI:1205338563
Name:MJD, LLC
Entity type:Organization
Organization Name:MJD, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHEL
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:DACCACHE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:702-750-9444
Mailing Address - Street 1:4544 S PECOS RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-5923
Mailing Address - Country:US
Mailing Address - Phone:702-436-0900
Mailing Address - Fax:702-436-0636
Practice Address - Street 1:4544 S PECOS RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-5923
Practice Address - Country:US
Practice Address - Phone:702-436-0900
Practice Address - Fax:702-436-0636
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MJD, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-03-02
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVS2-112C1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty