Provider Demographics
NPI:1265578587
Name:MICHAELIAN, ANDRE (DDS)
Entity type:Individual
Prefix:DR
First Name:ANDRE
Middle Name:
Last Name:MICHAELIAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8430 W LAKE MEAD BLVD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-7672
Mailing Address - Country:US
Mailing Address - Phone:702-220-9100
Mailing Address - Fax:702-220-9104
Practice Address - Street 1:8430 W LAKE MEAD BLVD
Practice Address - Street 2:SUITE 150
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-7672
Practice Address - Country:US
Practice Address - Phone:702-220-9100
Practice Address - Fax:702-220-9104
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV30761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002202034Medicaid