Provider Demographics
NPI:1316963861
Name:MADDISON AVE DENTAL
Entity type:Organization
Organization Name:MADDISON AVE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEAVITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-735-9500
Mailing Address - Street 1:4358 W CHEYENNE AVE
Mailing Address - Street 2:
Mailing Address - City:N LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032-2484
Mailing Address - Country:US
Mailing Address - Phone:702-735-9500
Mailing Address - Fax:702-693-6500
Practice Address - Street 1:4358 W CHEYENNE AVE
Practice Address - Street 2:
Practice Address - City:N LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-2484
Practice Address - Country:US
Practice Address - Phone:702-735-9500
Practice Address - Fax:702-693-6500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty