Provider Demographics
NPI:1336835222
Name:ULTRA DENTAL PEORIA LLC
Entity Type:Organization
Organization Name:ULTRA DENTAL PEORIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:
Authorized Official - Last Name:YASSO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:248-705-8334
Mailing Address - Street 1:8612 W MELINDA LN
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-2499
Mailing Address - Country:US
Mailing Address - Phone:248-705-8334
Mailing Address - Fax:
Practice Address - Street 1:8345 W THUNDERBIRD RD STE B100
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-3668
Practice Address - Country:US
Practice Address - Phone:602-943-3700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-13
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty