Provider Demographics
NPI:1154745677
Name:YACOUB, JOHN MEENA (DDS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:MEENA
Last Name:YACOUB
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 1:3018 208TH ST
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11360-2423
Mailing Address - Country:US
Mailing Address - Phone:718-909-9049
Mailing Address - Fax:
Practice Address - Street 1:30-18 208TH ST
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:14120
Practice Address - Country:US
Practice Address - Phone:718-909-9049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-05
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY058271122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist