Healthcare Provider Details

I. General information

NPI: 1811147796
Provider Name (Legal Business Name): KENNETH S. MASUMOTO DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2008
Last Update Date: 09/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 W. SHAW
FRESNO CA
93704
US

IV. Provider business mailing address

430 W. SHAW
FRESNO CA
93704
US

V. Phone/Fax

Practice location:
  • Phone: 559-229-1806
  • Fax: 559-229-5953
Mailing address:
  • Phone: 559-229-1806
  • Fax: 559-229-5953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number14139
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14139
License Number StateCA

VIII. Authorized Official

Name: DR. KENNETH SADAO MASUMOTO
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 559-229-1806