Healthcare Provider Details

I. General information

NPI: 1629287347
Provider Name (Legal Business Name): MIMI A YEUNG D.D.S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4420 DOUGLASTON PKWY SUITE 1-A
DOUGLASTON NY
11363-1841
US

IV. Provider business mailing address

4420 DOUGLASTON PKWY SUITE 1-A
DOUGLASTON NY
11363-1841
US

V. Phone/Fax

Practice location:
  • Phone: 718-767-6922
  • Fax: 718-225-0202
Mailing address:
  • Phone: 718-767-6922
  • Fax: 718-225-0202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number046258
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: