Healthcare Provider Details

I. General information

NPI: 1528624566
Provider Name (Legal Business Name): JASON CHAN YICK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2019
Last Update Date: 06/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9630 GROVE CIR N STE 102
MAPLE GROVE MN
55369-3480
US

IV. Provider business mailing address

9630 GROVE CIR N STE 102
MAPLE GROVE MN
55369-3480
US

V. Phone/Fax

Practice location:
  • Phone: 763-420-5484
  • Fax:
Mailing address:
  • Phone: 612-356-0289
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD14183
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: