Healthcare Provider Details

I. General information

NPI: 1134554298
Provider Name (Legal Business Name): MARK V YEZBICK RDH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2013
Last Update Date: 09/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27201 RYAN RD
WARREN MI
48092-5127
US

IV. Provider business mailing address

27201 RYAN RD
WARREN MI
48092-5127
US

V. Phone/Fax

Practice location:
  • Phone: 313-863-2800
  • Fax:
Mailing address:
  • Phone: 313-863-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2902010689
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: