Provider Demographics
NPI:1780051367
Name:MATTHEW KIKUCHI DMD PLLC
Entity type:Organization
Organization Name:MATTHEW KIKUCHI DMD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:KIKUCHI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:702-343-4720
Mailing Address - Street 1:5765 S FORT APACHE RD STE 110
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-5625
Mailing Address - Country:US
Mailing Address - Phone:702-876-6337
Mailing Address - Fax:702-876-2988
Practice Address - Street 1:5765 S FORT APACHE RD STE 110
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-5625
Practice Address - Country:US
Practice Address - Phone:702-876-6337
Practice Address - Fax:702-876-2988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-31
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVS2-138261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery