Healthcare Provider Details

I. General information

NPI: 1386064079
Provider Name (Legal Business Name): GRANT MATSUURA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2014
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 TRIVERTON AVE
LOS ANGELES CA
90095-0001
US

IV. Provider business mailing address

714 TRIVERTON AVE
LOS ANGELES CA
90095-0001
US

V. Phone/Fax

Practice location:
  • Phone: 310-206-3904
  • Fax:
Mailing address:
  • Phone: 801-580-4470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number112852
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: