Healthcare Provider Details

I. General information

NPI: 1265505408
Provider Name (Legal Business Name): JON DEREK YATSUSHIRO D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 08/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 NE 5TH ST
GRESHAM OR
97030-7308
US

IV. Provider business mailing address

320 NE 5TH ST
GRESHAM OR
97030-7308
US

V. Phone/Fax

Practice location:
  • Phone: 503-665-0495
  • Fax: 503-674-9196
Mailing address:
  • Phone: 503-665-0495
  • Fax: 503-674-9196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD7505
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number1571
License Number StateHI
# 3
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number35662
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: