Provider Demographics
NPI:1407063852
Name:FRED H. MATSUMOTO D.D.S., INC.
Entity Type:Organization
Organization Name:FRED H. MATSUMOTO D.D.S., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:HIROSHI
Authorized Official - Last Name:MATSUMOTO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:562-860-5597
Mailing Address - Street 1:11416 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-6611
Mailing Address - Country:US
Mailing Address - Phone:562-860-5597
Mailing Address - Fax:562-809-1947
Practice Address - Street 1:11416 SOUTH ST
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-6611
Practice Address - Country:US
Practice Address - Phone:562-860-5597
Practice Address - Fax:562-809-1947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA199321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty