Provider Demographics
NPI:1992071898
Name:JAN YAMASHIRO D.D.S., M.S.D., PROFESSIONAL LLC
Entity type:Organization
Organization Name:JAN YAMASHIRO D.D.S., M.S.D., PROFESSIONAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:YAMASHIRO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:303-443-3774
Mailing Address - Street 1:1717 FOLSOM ST
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-6718
Mailing Address - Country:US
Mailing Address - Phone:303-443-3774
Mailing Address - Fax:303-442-6651
Practice Address - Street 1:1717 FOLSOM ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-6718
Practice Address - Country:US
Practice Address - Phone:303-443-3774
Practice Address - Fax:303-442-6651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-26
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODT-103421223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty