Provider Demographics
NPI:1114927100
Name:YACOUB, KHALID M (DDS)
Entity Type:Individual
Prefix:
First Name:KHALID
Middle Name:M
Last Name:YACOUB
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 1:1008 E WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-6614
Mailing Address - Country:US
Mailing Address - Phone:619-334-1468
Mailing Address - Fax:619-328-4035
Practice Address - Street 1:1008 E WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-6614
Practice Address - Country:US
Practice Address - Phone:619-334-1468
Practice Address - Fax:619-328-4035
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-30
Last Update Date:2007-07-08
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
CA435101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG92696-01OtherDENTICAL