=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144144841
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PETER YACOUB
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2026
-----------------------------------------------------
Last Update Date | 08/05/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1685 CROWN AVE
-----------------------------------------------------
City | LANCASTER
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17601-6322
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-481-7645
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 49 LINDEN AVE
-----------------------------------------------------
City | BELLEVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07109-2719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DS046036
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------