=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083457808
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TONY YAMIN DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2024
-----------------------------------------------------
Last Update Date | 06/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29475 PLYMOUTH RD
-----------------------------------------------------
City | LIVONIA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48150-2112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-237-5755
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17176 BROOKVIEW DR
-----------------------------------------------------
City | LIVONIA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48152-4543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-707-0302
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 2901602056
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------