Provider Demographics
NPI:1699936542
Name:YANTES, ALICIA M (OD)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:M
Last Name:YANTES
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3480 BUNKER LAKE BLVD NW
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-2085
Mailing Address - Country:US
Mailing Address - Phone:763-712-9854
Mailing Address - Fax:
Practice Address - Street 1:3480 BUNKER LAKE BLVD NW
Practice Address - Street 2:SUITE 101
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-2085
Practice Address - Country:US
Practice Address - Phone:763-712-9854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3148152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist