Provider Demographics
NPI:1730914433
Name:TAHOE FACIAL PLASTIC SURGERY PLLC
Entity type:Organization
Organization Name:TAHOE FACIAL PLASTIC SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-936-3090
Mailing Address - Street 1:PO BOX 11195
Mailing Address - Street 2:
Mailing Address - City:ZEPHYR COVE
Mailing Address - State:NV
Mailing Address - Zip Code:89448-3195
Mailing Address - Country:US
Mailing Address - Phone:530-721-6052
Mailing Address - Fax:
Practice Address - Street 1:1600 MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89703-4625
Practice Address - Country:US
Practice Address - Phone:530-721-6052
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-04
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty