Healthcare Provider Details

I. General information

NPI: 1447664578
Provider Name (Legal Business Name): JACK YEUNG DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2014
Last Update Date: 06/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1222 MCCLELLAN DR APT 2
LOS ANGELES CA
90025-1010
US

IV. Provider business mailing address

1222 MCCLELLAN DR APT 2
LOS ANGELES CA
90025-1010
US

V. Phone/Fax

Practice location:
  • Phone: 415-730-2818
  • Fax:
Mailing address:
  • Phone: 415-730-2818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number63460
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: