Healthcare Provider Details

I. General information

NPI: 1063667590
Provider Name (Legal Business Name): DOUGLAS MICHAEL YARRIS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2008
Last Update Date: 11/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

716 2ND AVE
CROCKETT CA
94525-1111
US

IV. Provider business mailing address

716 2ND AVE
CROCKETT CA
94525-1111
US

V. Phone/Fax

Practice location:
  • Phone: 510-787-1471
  • Fax: 510-787-3018
Mailing address:
  • Phone: 510-787-1471
  • Fax: 510-787-3018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number031887
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: