=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073908349
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TONY YANG D.D.S., M.D. CORP.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2015
-----------------------------------------------------
Last Update Date | 07/22/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 113 WATERWORKS WAY SUITE 110
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92618-3167
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-393-5789
-----------------------------------------------------
Fax | 949-777-6168
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 113 WATERWORKS WAY SUITE 110
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92618-3167
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-393-5789
-----------------------------------------------------
Fax | 949-777-6168
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD
-----------------------------------------------------
Name | TONY YANG
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 949-393-5789
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QS0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery Clinic/Center
-----------------------------------------------------
License Number | OMS84
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------