MEDICARE: MJD, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	S2-112C	NV

General Provider Information

NPI Number	:	1205338563
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MJD, LLC

Provider Business Mailing Address
First Line	:	4544 S PECOS RD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-5923
Country	:	US
Telephone Number	:	702-436-0900
Fax Number	:	702-436-0636

Provider Business Practice Location Address
First Line	:	4544 S PECOS RD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-5923
Country	:	US
Telephone Number	:	702-436-0900
Fax Number	:	702-436-0636

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MICHEL JOSEPH DACCACHE
Credential	:	DDS
Telephone Number	:	702-750-9444

Provider Enumeration Date	:	03/02/2018
Last Update Date	:	03/02/2018

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