Healthcare Provider Details

I. General information

NPI: 1063361038
Provider Name (Legal Business Name): ULTRA DENTAL METRO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2026
Last Update Date: 01/23/2026
Certification Date: 01/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10621 N 35TH AVE
PHOENIX AZ
85029-4260
US

IV. Provider business mailing address

2938 E ROBIN LN
PHOENIX AZ
85050-8420
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

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