Provider Demographics
NPI:1033787379
Name:DONG, YANGBASAI
Entity Type:Individual
Prefix:
First Name:YANGBASAI
Middle Name:
Last Name:DONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5819 E RIVERSIDE BLVD # 21
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-4963
Mailing Address - Country:US
Mailing Address - Phone:815-282-4311
Mailing Address - Fax:815-282-4315
Practice Address - Street 1:5819 E RIVERSIDE BLVD # 21
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-4963
Practice Address - Country:US
Practice Address - Phone:815-282-4311
Practice Address - Fax:815-282-4315
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.033154122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist