=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285431767
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAXWELL ALLEN YANKEN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2025
-----------------------------------------------------
Last Update Date | 06/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1689 OLD PENDERGRASS RD STE 310
-----------------------------------------------------
City | JEFFERSON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30549-2716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-367-0010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 569 TURKEY CREEK CIR
-----------------------------------------------------
City | DUBLIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31021-2099
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-484-1661
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN123800
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------