Provider Demographics
NPI:1639713019
Name:MATSUOKA, KAZUYUKI (LD)
Entity Type:Individual
Prefix:MR
First Name:KAZUYUKI
Middle Name:
Last Name:MATSUOKA
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22524 SW 96TH DR
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-7398
Mailing Address - Country:US
Mailing Address - Phone:408-621-4747
Mailing Address - Fax:
Practice Address - Street 1:160 NE 6TH ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-3131
Practice Address - Country:US
Practice Address - Phone:451-265-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-29
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDT-DO-10197097122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist