Provider Demographics
NPI:1043362981
Name:ANTHEM VILLAGE DENTAL LLC
Entity type:Organization
Organization Name:ANTHEM VILLAGE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER IN CORPORATION
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:WILFORD
Authorized Official - Last Name:NISSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:702-454-7704
Mailing Address - Street 1:2571 ANTHEM VILLAGE DR
Mailing Address - Street 2:SUITE #5
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-5508
Mailing Address - Country:US
Mailing Address - Phone:702-454-7704
Mailing Address - Fax:702-454-0200
Practice Address - Street 1:2571 ANTHEM VILLAGE DR
Practice Address - Street 2:SUITE #5
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-5508
Practice Address - Country:US
Practice Address - Phone:702-454-7704
Practice Address - Fax:702-454-0200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1320741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty