Provider Demographics
NPI:1700409851
Name:YAKUBOV, KRISTINA (DDS)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:YAKUBOV
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 DEEPDALE PKWY
Mailing Address - Street 2:
Mailing Address - City:ROSLYN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11577-2302
Mailing Address - Country:US
Mailing Address - Phone:929-293-6791
Mailing Address - Fax:
Practice Address - Street 1:10505 69TH AVE APT 112A
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-3307
Practice Address - Country:US
Practice Address - Phone:929-293-6791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-23
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY062065-01122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program