Provider Demographics
NPI:1487884268
Name:DESERT DENTAL
Entity type:Organization
Organization Name:DESERT DENTAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ILYA
Authorized Official - Middle Name:
Authorized Official - Last Name:BENJAMIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:702-260-1890
Mailing Address - Street 1:55 S. VALLE VERDE DR.
Mailing Address - Street 2:SUITE #250
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89012
Mailing Address - Country:US
Mailing Address - Phone:702-260-1890
Mailing Address - Fax:702-260-7936
Practice Address - Street 1:55 S VALLE VERDE DR
Practice Address - Street 2:SUITE #250
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89012-3433
Practice Address - Country:US
Practice Address - Phone:702-260-1890
Practice Address - Fax:702-260-7936
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DESERT DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-15
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV58521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1326027095Medicaid