MEDICARE: ULTRA DENTAL MESA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)
2	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry
3	122300000X	Dentist

General Provider Information

NPI Number	:	1336072438
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ULTRA DENTAL MESA LLC

Provider Business Mailing Address
First Line	:	2938 E ROBIN LN
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85050-8420
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1116 S STAPLEY DR STE B108
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85204-5051
Country	:	US
Telephone Number	:	602-943-3700
Fax Number	:

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	DR. BOBBY YASSO
Credential	:	DMD
Telephone Number	:	248-705-8334

Provider Enumeration Date	:	06/08/2026
Last Update Date	:	06/08/2026

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