Healthcare Provider Details

I. General information

NPI: 1083611529
Provider Name (Legal Business Name): CLYDE YOST D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 PALO ALTO RD SUITE 400
SAN ANTONIO TX
78211-3772
US

IV. Provider business mailing address

102 PALO ALTO RD SUITE 400
SAN ANTONIO TX
78211-3772
US

V. Phone/Fax

Practice location:
  • Phone: 210-924-8770
  • Fax: 210-921-9650
Mailing address:
  • Phone: 210-924-8770
  • Fax: 210-921-9650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number12092
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: