Healthcare Provider Details

I. General information

NPI: 1336724897
Provider Name (Legal Business Name): AMANDA YACOUB
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2021
Last Update Date: 05/25/2023
Certification Date: 05/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11107 SUNSET HILLS RD STE 111
RESTON VA
20190-5481
US

IV. Provider business mailing address

11107 SUNSET HILLS RD STE 111
RESTON VA
20190-5481
US

V. Phone/Fax

Practice location:
  • Phone: 703-860-3200
  • Fax:
Mailing address:
  • Phone: 703-860-3200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN2000168
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401418068
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: