Healthcare Provider Details

I. General information

NPI: 1851094528
Provider Name (Legal Business Name): ULTRA DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2023
Last Update Date: 04/11/2023
Certification Date: 04/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

731 E UNION HILLS DR STE B7
PHOENIX AZ
85024-2910
US

IV. Provider business mailing address

8612 W MELINDA LN
PEORIA AZ
85382-2499
US

V. Phone/Fax

Practice location:
  • Phone: 602-613-8004
  • Fax: 602-613-8009
Mailing address:
  • Phone: 602-613-8004
  • Fax: 602-613-8009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. BOBBY YASSO
Title or Position: DENTIST
Credential: DMD
Phone: 602-613-8004