Provider Demographics
NPI:1063900595
Name:SUMMIT BOULEVARD DENTAL
Entity type:Organization
Organization Name:SUMMIT BOULEVARD DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:ADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:615-601-4728
Mailing Address - Street 1:13985 S VIRGINIA ST STE 806
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-8934
Mailing Address - Country:US
Mailing Address - Phone:775-846-4777
Mailing Address - Fax:775-525-5512
Practice Address - Street 1:13985 S VIRGINIA ST STE 806
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511-8934
Practice Address - Country:US
Practice Address - Phone:775-846-4777
Practice Address - Fax:775-525-5512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-30
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVS7-8811223E0200X
NVS7-88C122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1306026679OtherDENTISTRY