Provider Demographics
NPI:1043209257
Name:TAYSEER A IBRAHIM DDS PC
Entity Type:Organization
Organization Name:TAYSEER A IBRAHIM DDS PC
Other - Org Name:GRAND YEOMAN PARK DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TAYSEER
Authorized Official - Middle Name:AHMED
Authorized Official - Last Name:IBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-872-5530
Mailing Address - Street 1:1413 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-3601
Mailing Address - Country:US
Mailing Address - Phone:847-244-3322
Mailing Address - Fax:847-244-3318
Practice Address - Street 1:11316 W WADSWORTH RD
Practice Address - Street 2:
Practice Address - City:BEACH PARK
Practice Address - State:IL
Practice Address - Zip Code:60099-3367
Practice Address - Country:US
Practice Address - Phone:847-872-5530
Practice Address - Fax:847-872-1683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-19
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19-0254571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty