Provider Demographics
NPI:1255622635
Name:YANCEY, JOHN RUSSELL (DDS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:RUSSELL
Last Name:YANCEY
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 1:13403 ALPINE COVE DR
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:UT
Mailing Address - Zip Code:84004-1801
Mailing Address - Country:US
Mailing Address - Phone:317-459-0738
Mailing Address - Fax:
Practice Address - Street 1:11001 W 120TH AVE STE 400
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80021-3493
Practice Address - Country:US
Practice Address - Phone:317-459-0738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-20
Last Update Date:2019-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8020326-9924122300000X
UT8020326-99211223G0001X
390200000X
CODEN.002038571223D0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0004XDental ProvidersDentistDental AnesthesiologyGroup - Multi-Specialty
No122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program