Healthcare Provider Details

I. General information

NPI: 1336694231
Provider Name (Legal Business Name): YELM DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2016
Last Update Date: 08/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

718 W YELM AVE # 3
YELM WA
98597-8764
US

IV. Provider business mailing address

718 W YELM AVE # 3
YELM WA
98597-8764
US

V. Phone/Fax

Practice location:
  • Phone: 360-458-5606
  • Fax:
Mailing address:
  • Phone: 360-458-5606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE60674424
License Number StateWA

VIII. Authorized Official

Name: DR. STEPHEN E SMITH
Title or Position: OWNER
Credential: DMD
Phone: 360-458-5606