Provider Demographics
NPI:1407837594
Name:YAGHOUBIAN, SHAHROUKH (DDS)
Entity Type:Individual
Prefix:
First Name:SHAHROUKH
Middle Name:
Last Name:YAGHOUBIAN
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 1:1037 MORRIS AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10456-5816
Mailing Address - Country:US
Mailing Address - Phone:717-293-8005
Mailing Address - Fax:718-681-5515
Practice Address - Street 1:1037 MORRIS AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456-5816
Practice Address - Country:US
Practice Address - Phone:717-293-8005
Practice Address - Fax:718-681-5515
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0457721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice