Provider Demographics
NPI:1073297792
Name:IBRAHIM, NAGWAN
Entity Type:Individual
Prefix:
First Name:NAGWAN
Middle Name:
Last Name:IBRAHIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5800 N INTERSTATE 35 STE 205
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76207-1438
Mailing Address - Country:US
Mailing Address - Phone:940-220-7833
Mailing Address - Fax:
Practice Address - Street 1:8110 WESLEY ST STE 100
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75402-3936
Practice Address - Country:US
Practice Address - Phone:903-458-6819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-13
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX394841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice