Provider Demographics
NPI:1417067497
Name:SAIGUSA, MAKOTO (DMD, MD)
Entity Type:Individual
Prefix:DR
First Name:MAKOTO
Middle Name:
Last Name:SAIGUSA
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 TURTLE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-1937
Mailing Address - Country:US
Mailing Address - Phone:903-592-1664
Mailing Address - Fax:903-592-6595
Practice Address - Street 1:805 TURTLE CREEK DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1937
Practice Address - Country:US
Practice Address - Phone:903-592-1664
Practice Address - Fax:903-592-6595
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0551204E00000X
TX19097204E00000X, 1223S0112X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX090187801Medicaid
TX090187803Medicaid
TX133237107OtherCSHCN
TX090187802Medicaid
TX090187804Medicaid
TX090187802Medicaid
TX090187803Medicaid