Healthcare Provider Details

I. General information

NPI: 1003083940
Provider Name (Legal Business Name): MATTHEW RICHARD WIRIG D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2008
Last Update Date: 04/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 N STEPHANIE ST STE 211 120
HENDERSON NV
89014-8773
US

IV. Provider business mailing address

375 N STEPHANIE ST STE 211 120
HENDERSON NV
89014-8773
US

V. Phone/Fax

Practice location:
  • Phone: 702-454-1008
  • Fax: 702-454-1009
Mailing address:
  • Phone: 702-454-1008
  • Fax: 702-454-1009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5511
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberS3-175
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: