Provider Demographics
NPI:1003476565
Name:YAZBACK, ADAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:ADAM
Middle Name:
Last Name:YAZBACK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:ADAM
Other - Middle Name:
Other - Last Name:YAZBACK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:4853 WESTLAND ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-4112
Mailing Address - Country:US
Mailing Address - Phone:313-399-5088
Mailing Address - Fax:
Practice Address - Street 1:22211 W WARREN ST
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-2597
Practice Address - Country:US
Practice Address - Phone:313-982-3720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-17
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901600142122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist