Healthcare Provider Details

I. General information

NPI: 1881747012
Provider Name (Legal Business Name): FANNY YACAMAN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 N ROXBURY DR SUITE 703
BEVERLY HILLS CA
90210-4206
US

IV. Provider business mailing address

465 N ROXBURY DR SUITE 703
BEVERLY HILLS CA
90210-4206
US

V. Phone/Fax

Practice location:
  • Phone: 310-248-2336
  • Fax: 310-248-2886
Mailing address:
  • Phone: 310-248-2336
  • Fax: 310-248-2886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number47585
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: