Provider Demographics
NPI:1962569707
Name:MATSUEDA, RICHARD ROY (DDS)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ROY
Last Name:MATSUEDA
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 1:17511 CRENSHAW BLVD
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90504-3403
Mailing Address - Country:US
Mailing Address - Phone:310-323-3900
Mailing Address - Fax:
Practice Address - Street 1:17511 CRENSHAW BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90504-3403
Practice Address - Country:US
Practice Address - Phone:310-323-3900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA305961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA30596OtherSTATE DENTAL LICENSE