Healthcare Provider Details

I. General information

NPI: 1700400363
Provider Name (Legal Business Name): DR. BOBBY YASSO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2020
Last Update Date: 05/29/2020
Certification Date: 05/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1636 N 51ST AVE
PHOENIX AZ
85035-3936
US

IV. Provider business mailing address

18408 N 54TH LN
GLENDALE AZ
85308-1349
US

V. Phone/Fax

Practice location:
  • Phone: 602-904-5901
  • Fax:
Mailing address:
  • Phone: 248-705-8334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD010659
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD010659
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: