Provider Demographics
NPI:1063988202
Name:YUAN, YI (DMD)
Entity type:Individual
Prefix:
First Name:YI
Middle Name:
Last Name:YUAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:972 KIELY BLVD UNIT A
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95051-5073
Mailing Address - Country:US
Mailing Address - Phone:919-260-5111
Mailing Address - Fax:
Practice Address - Street 1:3161 SENTER RD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95111-1300
Practice Address - Country:US
Practice Address - Phone:919-260-5111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-15
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1030401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice