Provider Demographics
NPI:1568550036
Name:JACOUB, FAKHRY AZER (DDS)
Entity Type:Individual
Prefix:DR
First Name:FAKHRY
Middle Name:AZER
Last Name:JACOUB
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 1:12012 W WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-5893
Mailing Address - Country:US
Mailing Address - Phone:310-390-7981
Mailing Address - Fax:310-390-7982
Practice Address - Street 1:12012 W WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-5893
Practice Address - Country:US
Practice Address - Phone:310-390-7981
Practice Address - Fax:310-390-7982
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA331051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice