Provider Demographics
NPI:1083827976
Name:IRAWAN, IBRAHIM (DDS)
Entity Type:Individual
Prefix:DR
First Name:IBRAHIM
Middle Name:
Last Name:IRAWAN
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 1:505 E ARROW HWY
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-6034
Mailing Address - Country:US
Mailing Address - Phone:626-335-2899
Mailing Address - Fax:626-335-3892
Practice Address - Street 1:505 E ARROW HWY
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-6034
Practice Address - Country:US
Practice Address - Phone:626-335-2899
Practice Address - Fax:626-335-3892
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA371191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice