Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223X0400X | Orthodontists | DDS103359 | CA |
N | 1223X0400X | Orthodontists | S3-245C | NV |
NPI | 1053742742 |
---|---|
Provider Name | Dr. Pawan Gautam |
First Address | Las Vegas, NV 89169-4793 |
Second Address | Las Vegas, NV 89169-4793 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/12/2013 |
Last Update Date | 22/03/2019 |