Healthcare Provider Details

I. General information

NPI: 1114206158
Provider Name (Legal Business Name): MATTHEW T TOMODA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2011
Last Update Date: 06/01/2023
Certification Date: 06/01/2023
Deactivation Date: 04/12/2023
Reactivation Date: 06/01/2023

III. Provider practice location address

614 S MAIN ST
BLACKSBURG VA
24060-5259
US

IV. Provider business mailing address

1013 CANYON RIDGE RD APT 104
BLACKSBURG VA
24060-1277
US

V. Phone/Fax

Practice location:
  • Phone: 540-292-7662
  • Fax:
Mailing address:
  • Phone: 540-292-7662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0401413453
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: