=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083975304
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RHETT YEAKLEY DMD, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2012
-----------------------------------------------------
Last Update Date | 06/04/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1570 E HERITAGE PARK ST STE 100
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83646-5886
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-884-8066
-----------------------------------------------------
Fax | 208-884-4809
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1570 E HERITAGE PARK ST STE 100
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83646-5886
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-884-8066
-----------------------------------------------------
Fax | 208-884-4809
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. RHETT MATTHEW YEAKLEY
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 530-510-3884
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | D4338
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------