Provider Demographics
NPI:1093473605
Name:SHUAIB, IBRAHIM
Entity Type:Individual
Prefix:
First Name:IBRAHIM
Middle Name:
Last Name:SHUAIB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2516 72ND ST
Mailing Address - Street 2:
Mailing Address - City:EAST ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11370-1415
Mailing Address - Country:US
Mailing Address - Phone:929-655-9974
Mailing Address - Fax:
Practice Address - Street 1:2516 72ND ST
Practice Address - Street 2:
Practice Address - City:EAST ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11370-1415
Practice Address - Country:US
Practice Address - Phone:929-655-9974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-30
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29016011341223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics