Healthcare Provider Details

I. General information

NPI: 1457523755
Provider Name (Legal Business Name): JEEVAKA YAPA DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2008
Last Update Date: 09/05/2025
Certification Date: 09/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30555 GREENFIELD RD
SOUTHFIELD MI
48076-1594
US

IV. Provider business mailing address

30555 GREENFIELD RD
SOUTHFIELD MI
48076-1594
US

V. Phone/Fax

Practice location:
  • Phone: 248-262-9100
  • Fax: 248-262-9104
Mailing address:
  • Phone: 248-262-9100
  • Fax: 248-262-9104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number16026
License Number StateMI

VIII. Authorized Official

Name: KANESHA CANTY
Title or Position: OFFICE MANAGER
Credential:
Phone: 248-262-9100