Basic Information
| Provider Information | |||||||||
| NPI: | 1386064079 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATSUURA | ||||||||
| FirstName: | GRANT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5840 S MAJESTIC PINE DR | ||||||||
| Address2: | |||||||||
| City: | MURRAY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841076552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015804470 | ||||||||
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| Practice Location | |||||||||
| Address1: | 26 S 2000 E SUITE 5900 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015818951 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2014 | ||||||||
| LastUpdateDate: | 07/09/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 9291145-9922 | UT | Y | Dental Providers | Dentist | General Practice | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.