Provider Demographics
NPI:1316066046
Name:JABBOUR, NIZAM (DDS)
Entity type:Individual
Prefix:DR
First Name:NIZAM
Middle Name:
Last Name:JABBOUR
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 1:3 SHARON DR
Mailing Address - Street 2:
Mailing Address - City:FISHKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12524-1317
Mailing Address - Country:US
Mailing Address - Phone:845-440-3597
Mailing Address - Fax:845-454-0563
Practice Address - Street 1:153 ACADEMY ST
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-4521
Practice Address - Country:US
Practice Address - Phone:845-454-0560
Practice Address - Fax:845-454-0563
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047351-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02156036Medicaid