Healthcare Provider Details

I. General information

NPI: 1124518188
Provider Name (Legal Business Name): WILEY YAO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2018
Last Update Date: 09/28/2021
Certification Date: 07/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18130 HALSTED ST
HOMEWOOD IL
60430-2597
US

IV. Provider business mailing address

M205 CANDLEWOOD CT
MARSHFIELD WI
54449-8855
US

V. Phone/Fax

Practice location:
  • Phone: 708-799-2550
  • Fax:
Mailing address:
  • Phone: 715-897-7898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number021.003109
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: