=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265628291
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | YAX & STEC DENTAL ASSOCIATES, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2007
-----------------------------------------------------
Last Update Date | 11/15/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 58144 GRATIOT AVE SUITE 316
-----------------------------------------------------
City | NEW HAVEN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-749-3333
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 58144 GRATIOT AVE STE 316 P.O. BOX 480336
-----------------------------------------------------
City | NEW HAVEN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-749-3333
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | SUSAN ANN VENTURA
-----------------------------------------------------
Credential | MANAGER
-----------------------------------------------------
Telephone | 586-749-3333
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 2901011882
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------