Healthcare Provider Details

I. General information

NPI: 1124772181
Provider Name (Legal Business Name): KENSUKE MATSUMOTO, D.M.D., M.S., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2022
Last Update Date: 02/26/2022
Certification Date: 02/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8115 MARKET ST STE 208
WILMINGTON NC
28411-8430
US

IV. Provider business mailing address

8115 MARKET ST STE 208
WILMINGTON NC
28411-8430
US

V. Phone/Fax

Practice location:
  • Phone: 910-726-1000
  • Fax:
Mailing address:
  • Phone: 910-726-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. KENSUKE MATSUMOTO
Title or Position: PRESIDENT
Credential: DMD
Phone: 910-726-1000