Basic Information
| Provider Information | |||||||||
| NPI: | 1326069634 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANSDALE | ||||||||
| FirstName: | JERROLD | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1802 N CARSON ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CARSON CITY | ||||||||
| State: | NV | ||||||||
| PostalCode: | 897011265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7758886610 | ||||||||
| FaxNumber: | 7758877046 | ||||||||
| Practice Location | |||||||||
| Address1: | 2212 S EASTERN AVE | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891044124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7027359334 | ||||||||
| FaxNumber: | 7027359335 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 08/13/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 2050 | NV | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 1326069634 | 05 | NV | MEDICAID | 2050 | 01 | NV | NV DENTAL LICENSE | OTHER |