Healthcare Provider Details

I. General information

NPI: 1780051367
Provider Name (Legal Business Name): MATTHEW KIKUCHI DMD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2015
Last Update Date: 07/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5765 S FORT APACHE RD STE 110
LAS VEGAS NV
89148-5625
US

IV. Provider business mailing address

5765 S FORT APACHE RD STE 110
LAS VEGAS NV
89148-5625
US

V. Phone/Fax

Practice location:
  • Phone: 702-876-6337
  • Fax: 702-876-2988
Mailing address:
  • Phone: 702-876-6337
  • Fax: 702-876-2988

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License NumberS2-138
License Number StateNV

VIII. Authorized Official

Name: MATTHEW KIKUCHI
Title or Position: SOLE MEMBER
Credential: DMD
Phone: 702-343-4720