Provider Demographics
NPI:1629275151
Name:YAMASHIRO, DUANE K (DDS,MS)
Entity Type:Individual
Prefix:DR
First Name:DUANE
Middle Name:K
Last Name:YAMASHIRO
Suffix:
Gender:M
Credentials:DDS,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 MARIO CAPECCHI DR
Mailing Address - Street 2:STE 3575
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84113-1103
Mailing Address - Country:US
Mailing Address - Phone:801-662-3930
Mailing Address - Fax:801-662-3933
Practice Address - Street 1:100 N MEDICAL DR
Practice Address - Street 2:STE 3575
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1103
Practice Address - Country:US
Practice Address - Phone:801-662-3930
Practice Address - Fax:801-662-3933
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-28
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT141853-9921122300000X, 1223S0112X
UT1418531223P0221X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
No1223P0221XDental ProvidersDentistPediatric Dentistry
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY112651200Medicaid
ID805165800Medicaid
ID805165800Medicaid