Healthcare Provider Details

I. General information

NPI: 1033045679
Provider Name (Legal Business Name): YAH ORTHO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 ROYAL GORGE BLVD STE A
CANON CITY CO
81212-3835
US

IV. Provider business mailing address

3821 W PUEBLO BLVD
PUEBLO CO
81005-2713
US

V. Phone/Fax

Practice location:
  • Phone: 719-564-6464
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: RENEE CONSTUBLE
Title or Position: BUSINESS MANAGER
Credential:
Phone: 719-564-6464