Healthcare Provider Details

I. General information

NPI: 1386192052
Provider Name (Legal Business Name): YAKIMA ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2016
Last Update Date: 09/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 SUMMITVIEW AVE
YAKIMA WA
98902-3024
US

IV. Provider business mailing address

1107 SUMMITVIEW AVE
YAKIMA WA
98902-3024
US

V. Phone/Fax

Practice location:
  • Phone: 509-248-5181
  • Fax: 509-575-7967
Mailing address:
  • Phone: 509-248-5181
  • Fax: 509-575-7967

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDE60191920
License Number StateWA

VIII. Authorized Official

Name: KIANN JAEGER
Title or Position: OFFICE MANAGER
Credential:
Phone: 509-248-5181