Provider Demographics
NPI:1891365433
Name:MATSUMOTO, MIKA (DDS)
Entity Type:Individual
Prefix:
First Name:MIKA
Middle Name:
Last Name:MATSUMOTO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4547 8TH AVE NE APT 509
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-6707
Mailing Address - Country:US
Mailing Address - Phone:808-292-5396
Mailing Address - Fax:
Practice Address - Street 1:14655 BEL-RED ROAD
Practice Address - Street 2:UNIT 101
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98007
Practice Address - Country:US
Practice Address - Phone:425-641-4111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-27
Last Update Date:2021-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE61168232122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist