Provider Demographics
NPI:1659897049
Name:MATSUMOTO, BRIAN KOSHIRO (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:KOSHIRO
Last Name:MATSUMOTO
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 1:11611 IOWA AVE
Mailing Address - Street 2:#14
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025
Mailing Address - Country:US
Mailing Address - Phone:310-948-9394
Mailing Address - Fax:
Practice Address - Street 1:500 ALA MOANA BOULEVARD
Practice Address - Street 2:SEVEN WATERFRONT PLAZA, #220
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813
Practice Address - Country:US
Practice Address - Phone:808-523-3104
Practice Address - Fax:808-523-3121
Is Sole Proprietor?:No
Enumeration Date:2017-08-17
Last Update Date:2017-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT-27151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice