Healthcare Provider Details

I. General information

NPI: 1194783886
Provider Name (Legal Business Name): MARK PAUL YATES DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11100 W MICHIGAN AVE
YOUNGTOWN AZ
85363
US

IV. Provider business mailing address

515 E CAREFREE HWY PMB 834
PHOENIX AZ
85085
US

V. Phone/Fax

Practice location:
  • Phone: 623-974-5629
  • Fax:
Mailing address:
  • Phone: 623-465-2231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD6484
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: