Healthcare Provider Details

I. General information

NPI: 1972899391
Provider Name (Legal Business Name): MATTHEW THOMAS MATTEUCCI DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2011
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2764 LAKE SAHARA DR
LAS VEGAS NV
89117-3400
US

IV. Provider business mailing address

2764 LAKE SAHARA DR
LAS VEGAS NV
89117-3400
US

V. Phone/Fax

Practice location:
  • Phone: 702-365-6497
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number6100
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6100
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: