Provider Demographics
NPI:1790904357
Name:MATSUMOTO, ROBERT DOUGLAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:DOUGLAS
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 1:114 W IVY ST
Mailing Address - Street 2:
Mailing Address - City:HANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:93230-3820
Mailing Address - Country:US
Mailing Address - Phone:559-584-8237
Mailing Address - Fax:559-584-0916
Practice Address - Street 1:114 W IVY ST
Practice Address - Street 2:
Practice Address - City:HANFORD
Practice Address - State:CA
Practice Address - Zip Code:93230-3820
Practice Address - Country:US
Practice Address - Phone:559-584-8237
Practice Address - Fax:559-584-0916
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25943122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist