Provider Demographics
NPI:1407540768
Name:YACOUB, MARCO (DMD)
Entity Type:Individual
Prefix:
First Name:MARCO
Middle Name:
Last Name:YACOUB
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:474 UNION HILL RD
Mailing Address - Street 2:
Mailing Address - City:ENGLISHTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07726-1849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3512 CADUCEUS DR
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-2902
Practice Address - Country:US
Practice Address - Phone:843-293-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-07
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCDGD.105301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice