Provider Demographics
NPI:1366811747
Name:LONE MOUNTAIN FAMILY DENTAL
Entity type:Organization
Organization Name:LONE MOUNTAIN FAMILY DENTAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:ETMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:702-655-9533
Mailing Address - Street 1:4818 W LONE MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130-2239
Mailing Address - Country:US
Mailing Address - Phone:702-655-9533
Mailing Address - Fax:702-655-9565
Practice Address - Street 1:4818 W LONE MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-2239
Practice Address - Country:US
Practice Address - Phone:702-655-9533
Practice Address - Fax:702-655-9565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-16
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6547305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization