Healthcare Provider Details

I. General information

NPI: 1669178497
Provider Name (Legal Business Name): GEORGE YACOUB
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2023
Last Update Date: 06/24/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 NW 107TH AVE FL 3
DORAL FL
33178-4377
US

IV. Provider business mailing address

3601 NW 107TH AVE FL 3
DORAL FL
33178-4377
US

V. Phone/Fax

Practice location:
  • Phone: 305-418-7771
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN29832
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: