Provider Demographics
NPI:1720186745
Name:YAKOBASHVILI, GURAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:GURAM
Middle Name:
Last Name:YAKOBASHVILI
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 1:293 E 149TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10451-5601
Mailing Address - Country:US
Mailing Address - Phone:646-404-5005
Mailing Address - Fax:646-404-5006
Practice Address - Street 1:293 E 149TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-5601
Practice Address - Country:US
Practice Address - Phone:646-404-5005
Practice Address - Fax:646-404-5006
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI202801223G0001X
NY05583111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8444706Medicaid
NY03395140Medicaid