Provider Demographics
NPI:1144732413
Name:REDIC, DANTE DENECKO
Entity type:Individual
Prefix:MR
First Name:DANTE
Middle Name:DENECKO
Last Name:REDIC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 FAIRCHILD ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89110-1811
Mailing Address - Country:US
Mailing Address - Phone:702-682-8844
Mailing Address - Fax:
Practice Address - Street 1:1650 COMMUNITY COLLEGE DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-1144
Practice Address - Country:US
Practice Address - Phone:702-682-8844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-26
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician