Healthcare Provider Details

I. General information

NPI: 1568917342
Provider Name (Legal Business Name): MARIA YEASH D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2016
Last Update Date: 08/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 MEMORIAL DR
POCATELLO ID
83201-4008
US

IV. Provider business mailing address

465 MEMORIAL DR
POCATELLO ID
83201-4008
US

V. Phone/Fax

Practice location:
  • Phone: 208-282-6000
  • Fax:
Mailing address:
  • Phone: 208-282-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD-4765
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: