Provider Demographics
NPI:1396993911
Name:SHORT, YOLANDA ALEJANDRINO (DMD)
Entity type:Individual
Prefix:DR
First Name:YOLANDA
Middle Name:ALEJANDRINO
Last Name:SHORT
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:YOLANDA
Other - Middle Name:ALEJANDRINO
Other - Last Name:LE VAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2751 E REDFIELD RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-5648
Mailing Address - Country:US
Mailing Address - Phone:303-999-1672
Mailing Address - Fax:
Practice Address - Street 1:1819 W DUNLAP AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-4375
Practice Address - Country:US
Practice Address - Phone:602-861-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-08
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN-97581223G0001X
AZ86761223G0001X
CA632031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ838111Medicaid
CO56201346Medicaid