Healthcare Provider Details

I. General information

NPI: 1326003617
Provider Name (Legal Business Name): TODD TAKEO MATSUMOTO D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 12/13/2019
Certification Date: 12/13/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2635 GATEWAY RD STE 101
CARLSBAD CA
92009-1753
US

IV. Provider business mailing address

12481 S LA COSTE DR
TUSTIN CA
92782-0943
US

V. Phone/Fax

Practice location:
  • Phone: 760-444-4094
  • Fax:
Mailing address:
  • Phone: 714-783-8308
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDE00007805
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number54489
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: