Healthcare Provider Details

I. General information

NPI: 1740460187
Provider Name (Legal Business Name): YACOUB A PROFESSIONAL DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2007
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 E WASHINGTON AVE
EL CAJON CA
92020
US

IV. Provider business mailing address

1008 E WASHINGTON AVE
EL CAJON CA
92020-6614
US

V. Phone/Fax

Practice location:
  • Phone: 619-334-1468
  • Fax: 619-328-4035
Mailing address:
  • Phone: 619-334-1468
  • Fax: 619-328-4035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number43510
License Number StateCA

VIII. Authorized Official

Name: KHALID MARQUS YACOUB
Title or Position: OWNER
Credential: DDS
Phone: 619-334-1468