Provider Demographics
NPI:1114679750
Name:THOMAS S MATTEUCCI DDS LTD
Entity Type:Organization
Organization Name:THOMAS S MATTEUCCI DDS LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTEUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:702-365-6499
Mailing Address - Street 1:2764 LAKE SAHARA DR STE 107
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-3400
Mailing Address - Country:US
Mailing Address - Phone:702-365-6499
Mailing Address - Fax:702-221-8465
Practice Address - Street 1:2764 LAKE SAHARA DR STE 107
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-3400
Practice Address - Country:US
Practice Address - Phone:702-365-6499
Practice Address - Fax:702-221-8465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-25
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1972899391Medicaid