Healthcare Provider Details

I. General information

NPI: 1922019454
Provider Name (Legal Business Name): KENNETH MARTIN YATES D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9735 WILSHIRE BLVD SUITE 200
BEVERLY HILLS CA
90212-2107
US

IV. Provider business mailing address

9735 WILSHIRE BLVD SUITE 200
BEVERLY HILLS CA
90212-2107
US

V. Phone/Fax

Practice location:
  • Phone: 310-275-5581
  • Fax: 310-271-8815
Mailing address:
  • Phone: 310-275-5581
  • Fax: 310-271-8815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number30679
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: