Provider Demographics
NPI:1114206158
Name:TOMODA, MATTHEW T (DDS)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:T
Last Name:TOMODA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1013 CANYON RIDGE RD APT 104
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-1277
Mailing Address - Country:US
Mailing Address - Phone:540-292-7662
Mailing Address - Fax:
Practice Address - Street 1:614 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-5259
Practice Address - Country:US
Practice Address - Phone:540-292-7662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-09
Last Update Date:2023-06-01
Deactivation Date:2023-04-12
Deactivation Code:
Reactivation Date:2023-06-01
Provider Licenses
StateLicense IDTaxonomies
DC390200000X
VA0401413453122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program