Provider Demographics
NPI:1487942678
Name:MATSUURA, BLAKE TK (DDS)
Entity type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:TK
Last Name:MATSUURA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98-1256 KAAHUMANU ST STE E303
Mailing Address - Street 2:
Mailing Address - City:PEARL CITY
Mailing Address - State:HI
Mailing Address - Zip Code:96782-3282
Mailing Address - Country:US
Mailing Address - Phone:808-488-1988
Mailing Address - Fax:
Practice Address - Street 1:98-1256 KAAHUMANU ST STE E303
Practice Address - Street 2:
Practice Address - City:PEARL CITY
Practice Address - State:HI
Practice Address - Zip Code:96782-3282
Practice Address - Country:US
Practice Address - Phone:808-488-1988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-21
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT-24461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice