Provider Demographics
NPI:1265505408
Name:YATSUSHIRO, JON DEREK (DDS)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:DEREK
Last Name:YATSUSHIRO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 NE 5TH ST
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-7308
Mailing Address - Country:US
Mailing Address - Phone:503-665-0495
Mailing Address - Fax:503-674-9196
Practice Address - Street 1:320 NE 5TH ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7308
Practice Address - Country:US
Practice Address - Phone:503-665-0495
Practice Address - Fax:503-674-9196
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD75051223E0200X
HI15711223E0200X
CA356621223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics