=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730408915
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | YAROSLAV R YARMOLYUK DDS, MS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2010
-----------------------------------------------------
Last Update Date | 06/15/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1020 S ARLINGTON HEIGHTS RD
-----------------------------------------------------
City | ARLINGTON HEIGHTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60005-3169
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-749-4340
-----------------------------------------------------
Fax | 847-739-7570
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5449 TALL OAKS DR
-----------------------------------------------------
City | LONG GROVE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-691-9401
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 021.002488
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------