Provider Demographics
NPI:1508911819
Name:YACOUB, NIDAL (DMD, MDS)
Entity Type:Individual
Prefix:DR
First Name:NIDAL
Middle Name:
Last Name:YACOUB
Suffix:
Gender:M
Credentials:DMD, MDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 PERSHING BLVD
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:PA
Mailing Address - Zip Code:18052-6452
Mailing Address - Country:US
Mailing Address - Phone:610-434-6796
Mailing Address - Fax:
Practice Address - Street 1:450 PERSHING BLVD
Practice Address - Street 2:
Practice Address - City:WHITEHALL
Practice Address - State:PA
Practice Address - Zip Code:18052-6452
Practice Address - Country:US
Practice Address - Phone:610-434-6796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS031269L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017994360002Medicaid