Healthcare Provider Details

I. General information

NPI: 1336072438
Provider Name (Legal Business Name): ULTRA DENTAL MESA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1116 S STAPLEY DR STE B108
MESA AZ
85204-5051
US

IV. Provider business mailing address

2938 E ROBIN LN
PHOENIX AZ
85050-8420
US

V. Phone/Fax

Practice location:
  • Phone: 602-943-3700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. BOBBY YASSO
Title or Position: OWNER/DENTIST
Credential: DMD
Phone: 248-705-8334