Provider Demographics
NPI:1720346117
Name:NORTHERN NEVADA DENTAL SPECIALTIES GROUP
Entity Type:Organization
Organization Name:NORTHERN NEVADA DENTAL SPECIALTIES GROUP
Other - Org Name:MY KID'S SMILE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:J
Authorized Official - Middle Name:JUSTIN
Authorized Official - Last Name:WILKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:775-823-9797
Mailing Address - Street 1:10645 DOUBLE R BLVD
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89521-8920
Mailing Address - Country:US
Mailing Address - Phone:775-852-6164
Mailing Address - Fax:775-284-7352
Practice Address - Street 1:10645 DOUBLE R BLVD
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89521-8920
Practice Address - Country:US
Practice Address - Phone:775-852-6164
Practice Address - Fax:775-284-7352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-24
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVS6-201223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty