Healthcare Provider Details

I. General information

NPI: 1629275151
Provider Name (Legal Business Name): DUANE K YAMASHIRO DDS,MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 12/20/2021
Certification Date: 12/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N MEDICAL DR STE 3575
SALT LAKE CITY UT
84113-1103
US

IV. Provider business mailing address

100 MARIO CAPECCHI DR STE 3575
SALT LAKE CITY UT
84113-1103
US

V. Phone/Fax

Practice location:
  • Phone: 801-662-3930
  • Fax: 801-662-3933
Mailing address:
  • Phone: 801-662-3930
  • Fax: 801-662-3933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number141853-9921
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number141853
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number141853-9921
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number141853
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: