Provider Demographics
NPI:1013968924
Name:KHAN, YAQOOB NAWAZ (DMD)
Entity Type:Individual
Prefix:
First Name:YAQOOB
Middle Name:NAWAZ
Last Name:KHAN
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 1:50 AUERT AVE
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-2326
Mailing Address - Country:US
Mailing Address - Phone:316-266-0000
Mailing Address - Fax:315-266-0126
Practice Address - Street 1:50 AUERT AVE
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-2326
Practice Address - Country:US
Practice Address - Phone:316-266-0000
Practice Address - Fax:315-266-0126
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0517591223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02592914Medicaid
NY9177697OtherDORAL