Healthcare Provider Details

I. General information

NPI: 1619338449
Provider Name (Legal Business Name): YAKOV YAKUBOV
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2016
Last Update Date: 07/04/2022
Certification Date: 07/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 CEDAR LN
TEANECK NJ
07666-3442
US

IV. Provider business mailing address

315 CEDAR LN
TEANECK NJ
07666-3442
US

V. Phone/Fax

Practice location:
  • Phone: 201-692-7737
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number22DI02667300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: