Provider Demographics
NPI:1144842626
Name:POUYA MOMTAZ DMD PLLC
Entity type:Organization
Organization Name:POUYA MOMTAZ DMD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:POUYA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOMTAZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD MS
Authorized Official - Phone:702-546-9936
Mailing Address - Street 1:6121 W LAKE MEAD BLVD STE 115
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-2737
Mailing Address - Country:US
Mailing Address - Phone:702-381-9444
Mailing Address - Fax:
Practice Address - Street 1:6121 W LAKE MEAD BLVD STE 115
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89108-2737
Practice Address - Country:US
Practice Address - Phone:702-381-9444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:POUYA MOMTAZ DMD PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-05-07
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty