Provider Demographics
NPI:1639830243
Name:YACOUB, ESMA ANWAR (DMD)
Entity Type:Individual
Prefix:
First Name:ESMA
Middle Name:ANWAR
Last Name:YACOUB
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 1:16944 S HIGHLAND AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-3467
Mailing Address - Country:US
Mailing Address - Phone:909-275-7179
Mailing Address - Fax:
Practice Address - Street 1:16944 S HIGHLAND AVE STE 400
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-3467
Practice Address - Country:US
Practice Address - Phone:909-275-7179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-05
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA1077931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program