Healthcare Provider Details

I. General information

NPI: 1285254250
Provider Name (Legal Business Name): YAZAN AHMAD ALKHAWAM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2020
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 MAIN ST
SOUTH AMBOY NJ
08879-1634
US

IV. Provider business mailing address

360 MAIN ST
SOUTH AMBOY NJ
08879-1634
US

V. Phone/Fax

Practice location:
  • Phone: 732-721-1166
  • Fax:
Mailing address:
  • Phone: 732-721-1166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number22DI02816600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: