Healthcare Provider Details

I. General information

NPI: 1760185656
Provider Name (Legal Business Name): NIZAM JABBOUR DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2023
Last Update Date: 03/24/2023
Certification Date: 03/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 ACADEMY ST
POUGHKEEPSIE NY
12601-4567
US

IV. Provider business mailing address

2 CLARINBRIDGE CT
HOPEWELL JUNCTION NY
12533-3325
US

V. Phone/Fax

Practice location:
  • Phone: 845-454-0560
  • Fax:
Mailing address:
  • Phone: 845-454-0560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NIZAM JABBOUR
Title or Position: DDS
Credential: DENTIST
Phone: 845-454-0560