MEDICARE: MATTHEW KIKUCHI DMD PLLC

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	261QS0112X	Oral and Maxillofacial Surgery Clinic/Center	S2-138	NV

General Provider Information

NPI Number	:	1780051367
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MATTHEW KIKUCHI DMD PLLC

Provider Business Mailing Address
First Line	:	5765 S FORT APACHE RD STE 110
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89148-5625
Country	:	US
Telephone Number	:	702-876-6337
Fax Number	:	702-876-2988

Provider Business Practice Location Address
First Line	:	5765 S FORT APACHE RD STE 110
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89148-5625
Country	:	US
Telephone Number	:	702-876-6337
Fax Number	:	702-876-2988

Authorized Official
Title or Position	:	SOLE MEMBER
Name	:	MATTHEW KIKUCHI
Credential	:	DMD
Telephone Number	:	702-343-4720

Provider Enumeration Date	:	08/31/2015
Last Update Date	:	07/19/2019

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