Provider Demographics
NPI:1891358172
Name:YACOUB, MARKO (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARKO
Middle Name:
Last Name:YACOUB
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25209 NARBONNE AVE
Mailing Address - Street 2:
Mailing Address - City:LOMITA
Mailing Address - State:CA
Mailing Address - Zip Code:90717-2121
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25209 NARBONNE AVE
Practice Address - Street 2:
Practice Address - City:LOMITA
Practice Address - State:CA
Practice Address - Zip Code:90717-2121
Practice Address - Country:US
Practice Address - Phone:310-539-4166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-22
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS042599122300000X
390200000X
CADDS1074461223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program