Provider Demographics
NPI:1033887856
Name:AL-MUTAWA, IBRAHIM AHMED (DDS)
Entity Type:Individual
Prefix:DR
First Name:IBRAHIM
Middle Name:AHMED
Last Name:AL-MUTAWA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 N EISENHOWER DR APT E7
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049-5133
Mailing Address - Country:US
Mailing Address - Phone:816-810-8434
Mailing Address - Fax:
Practice Address - Street 1:1730 SW WANAMAKER RD
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66604-3813
Practice Address - Country:US
Practice Address - Phone:785-338-4048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-06
Last Update Date:2021-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS61948122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist