Healthcare Provider Details

I. General information

NPI: 1689916405
Provider Name (Legal Business Name): MILES JONATHAN YACKER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2013
Last Update Date: 03/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 CENTRAL AVE SUITE 201
LAWRENCE NY
11559-8507
US

IV. Provider business mailing address

290 CENTRAL AVE SUITE 201
LAWRENCE NY
11559-8507
US

V. Phone/Fax

Practice location:
  • Phone: 516-239-7432
  • Fax: 516-239-4330
Mailing address:
  • Phone: 516-239-7432
  • Fax: 516-239-4330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number034332
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: