Provider Demographics
NPI:1548785462
Name:YADAV, POONAM (DMD)
Entity Type:Individual
Prefix:DR
First Name:POONAM
Middle Name:
Last Name:YADAV
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 KELLY DRIVER RD
Mailing Address - Street 2:
Mailing Address - City:CLEMENTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08021-4823
Mailing Address - Country:US
Mailing Address - Phone:347-957-9352
Mailing Address - Fax:
Practice Address - Street 1:3, KELLY DRIVERS LN
Practice Address - Street 2:
Practice Address - City:LAUREL SPRINGS
Practice Address - State:NJ
Practice Address - Zip Code:08021
Practice Address - Country:US
Practice Address - Phone:856-258-7064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-11
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS041397122300000X
NJ22DI027088001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist