Provider Demographics
NPI:1114324456
Name:MATSUMORI DENTAL, PLLC
Entity Type:Organization
Organization Name:MATSUMORI DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:DEVIN
Authorized Official - Middle Name:T
Authorized Official - Last Name:MATSUMORI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-571-8391
Mailing Address - Street 1:870 E 9400 S STE 110
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-3689
Mailing Address - Country:US
Mailing Address - Phone:801-571-8391
Mailing Address - Fax:801-571-8285
Practice Address - Street 1:870 E 9400 S STE 110
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-3689
Practice Address - Country:US
Practice Address - Phone:801-571-8391
Practice Address - Fax:801-571-8285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-02
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7987460-9921261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental