MEDICARE: DR. WAYNE ICHIKAWA D.D.S., M.S.

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)	29954	CA
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	S2-147C	NV

General Provider Information

NPI Number	:	1477604627
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WAYNE ICHIKAWA D.D.S., M.S.

Provider Business Mailing Address
First Line	:	1001 SHADOW LN # MS 7413
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89106-4124
Country	:	US
Telephone Number	:	702-774-2457
Fax Number	:	702-774-2610

Provider Business Practice Location Address
First Line	:	1001 SHADOW LN # MS 7413
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89106-4124
Country	:	US
Telephone Number	:	702-774-2457
Fax Number	:	702-774-2610

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/15/2007
Last Update Date	:	03/08/2019

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