Provider Demographics
NPI:1619907508
Name:TADRISSI, MARK KEYAN (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:KEYAN
Last Name:TADRISSI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7720 W SAHARA AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-2754
Mailing Address - Country:US
Mailing Address - Phone:702-862-4088
Mailing Address - Fax:
Practice Address - Street 1:7720 W SAHARA AVE STE 107
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-2754
Practice Address - Country:US
Practice Address - Phone:702-862-4088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV30861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice