Provider Demographics
NPI:1972638070
Name:YACOUB, KINDA HANNA (DDS)
Entity Type:Individual
Prefix:
First Name:KINDA
Middle Name:HANNA
Last Name:YACOUB
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 1:399 HOOVER AVE
Mailing Address - Street 2:SUITE #1
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003
Mailing Address - Country:US
Mailing Address - Phone:973-566-6161
Mailing Address - Fax:973-566-0866
Practice Address - Street 1:399 HOOVER AVE
Practice Address - Street 2:SUITE #1
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003
Practice Address - Country:US
Practice Address - Phone:973-566-6161
Practice Address - Fax:973-566-0866
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI020914122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ9014306Medicaid