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General NPI Number Information
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NPI Number | 1336835222
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Entity Type | Organization
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Legal Business Name | ULTRA DENTAL PEORIA LLC
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Dates
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Enumeration Date | 04/13/2023
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Last Update Date | 04/13/2023
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Provider Practice Location Address
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Address Line | 8345 W THUNDERBIRD RD STE B100
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City | PEORIA
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State | AZ
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Zip | 85381-3668
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Country | US
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Telephone | 602-943-3700
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Fax |
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Provider Business Mailing Address
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Address Line | 8612 W MELINDA LN
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City | PEORIA
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State | AZ
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Zip | 85382-2499
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Country | US
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Telephone | 248-705-8334
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Fax |
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Authorized Official
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Title or Position | GENERAL DENTIST
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Name | DR. BOBBY YASSO
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Credential | DMD
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Telephone | 248-705-8334
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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