Healthcare Provider Details

I. General information

NPI: 1275233942
Provider Name (Legal Business Name): AUGUSTO TOKUMOTO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2023
Last Update Date: 10/27/2023
Certification Date: 10/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38 WORCESTER SQ APT 6
BOSTON MA
02118-3599
US

IV. Provider business mailing address

38 WORCESTER SQ APT 6
BOSTON MA
02118-3599
US

V. Phone/Fax

Practice location:
  • Phone: 973-510-3515
  • Fax:
Mailing address:
  • Phone: 973-510-3515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN1859970
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: