Basic Information
| Provider Information | |||||||||
| NPI: | 1780038257 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FIRST PERSON CARE CLINIC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HUNTRIDGE DENTAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 S 4TH ST STE 111 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891041046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023808118 | ||||||||
| FaxNumber: | 7023802929 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 S 4TH ST STE 109 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891041046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7025750866 | ||||||||
| FaxNumber: | 7023692162 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2016 | ||||||||
| LastUpdateDate: | 12/05/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VALETON | ||||||||
| AuthorizedOfficialFirstName: | ROXANA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7023808118 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223D0001X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Dental Public Health | 1223D0004X | N | 193200000X MULTI-SPECIALTY GROUP | 1223P0221X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Pediatric Dentistry | 124Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dental Hygienist | 126800000X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dental Assistant | 261QD0000X | N | Ambulatory Health Care Facilities | Clinic/Center | Dental | 1223G0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 1780038257 | 05 | NV | MEDICAID |