Healthcare Provider Details

I. General information

NPI: 1225327281
Provider Name (Legal Business Name): DEVIN T MATSUMORI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2011
Last Update Date: 12/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

870 E 9400 S
SANDY UT
84094-3666
US

IV. Provider business mailing address

870 E 9400 S STE 110
SANDY UT
84094-3689
US

V. Phone/Fax

Practice location:
  • Phone: 801-571-8391
  • Fax:
Mailing address:
  • Phone: 801-571-8391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7987460-9921
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD008150
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: