Provider Demographics
NPI:1700400363
Name:YASSO, BOBBY
Entity Type:Individual
Prefix:DR
First Name:BOBBY
Middle Name:
Last Name:YASSO
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 1:18408 N 54TH LN
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-1349
Mailing Address - Country:US
Mailing Address - Phone:248-705-8334
Mailing Address - Fax:
Practice Address - Street 1:1636 N 51ST AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85035-3936
Practice Address - Country:US
Practice Address - Phone:602-904-5901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-29
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0106591223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice