Provider Demographics
NPI:1639168701
Name:WHITEHALL DENTAL ASSOC
Entity Type:Organization
Organization Name:WHITEHALL DENTAL ASSOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NIDAL
Authorized Official - Middle Name:
Authorized Official - Last Name:YACOUB
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MDS
Authorized Official - Phone:610-360-9625
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:610-434-6671
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:610-434-6671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-20
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS031269L1223G0001X
PAMD418291207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1799436Medicaid
PA0018794480004Medicaid
PA0018794480004Medicaid