Provider Demographics
NPI:1386064079
Name:MATSUURA, GRANT
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:MATSUURA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5840 S MAJESTIC PINE DR
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-6552
Mailing Address - Country:US
Mailing Address - Phone:801-580-4470
Mailing Address - Fax:
Practice Address - Street 1:26 S 2000 E SUITE 5900
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84112
Practice Address - Country:US
Practice Address - Phone:801-581-8951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-21
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9291145-99221223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program