Provider Demographics
NPI:1083119374
Name:IBARRA, DEREK (DDS)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:IBARRA
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 1:2900 UNIVERSITY AVE SE APT 510
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-3738
Mailing Address - Country:US
Mailing Address - Phone:319-321-6426
Mailing Address - Fax:
Practice Address - Street 1:12700 N FEATHERWOOD DR STE 290
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77034-4496
Practice Address - Country:US
Practice Address - Phone:819-494-4562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-28
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX370461223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty