Provider Demographics
NPI:1053369975
Name:MATSUMOTO, MARK MATTHEW (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:MATTHEW
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 1:5201 EDEN AVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55436-2316
Mailing Address - Country:US
Mailing Address - Phone:952-746-0225
Mailing Address - Fax:952-746-0225
Practice Address - Street 1:5201 EDEN AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55436-2316
Practice Address - Country:US
Practice Address - Phone:952-746-0225
Practice Address - Fax:952-746-0225
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND89021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice