Provider Demographics
NPI:1477604627
Name:ICHIKAWA, WAYNE (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:
Last Name:ICHIKAWA
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 SHADOW LN # MS 7413
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4124
Mailing Address - Country:US
Mailing Address - Phone:702-774-2457
Mailing Address - Fax:702-774-2610
Practice Address - Street 1:1001 SHADOW LN # MS 7413
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4124
Practice Address - Country:US
Practice Address - Phone:702-774-2457
Practice Address - Fax:702-774-2610
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA299541223S0112X
NVS2-147C1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery