Provider Demographics
NPI:1861235632
Name:TAKAHASHI, MATTHEW G (DDS)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:G
Last Name:TAKAHASHI
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 1:866 LAZELLE ST
Mailing Address - Street 2:
Mailing Address - City:STURGIS
Mailing Address - State:SD
Mailing Address - Zip Code:57785-1611
Mailing Address - Country:US
Mailing Address - Phone:605-347-8880
Mailing Address - Fax:605-347-2011
Practice Address - Street 1:866 LAZELLE ST
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:SD
Practice Address - Zip Code:57785-1611
Practice Address - Country:US
Practice Address - Phone:605-347-8880
Practice Address - Fax:605-347-2011
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-18
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDD14481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice