Provider Demographics
NPI:1528624566
Name:YICK, JASON CHAN (DDS)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:CHAN
Last Name:YICK
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 1:9630 GROVE CIR N STE 102
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-3480
Mailing Address - Country:US
Mailing Address - Phone:612-356-0289
Mailing Address - Fax:
Practice Address - Street 1:9630 GROVE CIR N STE 102
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-3480
Practice Address - Country:US
Practice Address - Phone:763-420-5484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-15
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND14183122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist