Provider Demographics
NPI:1093846974
Name:IBRAHIM, MONA RIZK (DDS, MPH, MS)
Entity Type:Individual
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First Name:MONA
Middle Name:RIZK
Last Name:IBRAHIM
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Gender:F
Credentials:DDS, MPH, MS
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Other - Middle Name:
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Mailing Address - Street 1:DETROIT HEALTH DEPT. - HERMAN KIEFER HEALTH COMPLEX
Mailing Address - Street 2:1151 TAYLOR STREET, 7TH FLOOR PEDIATRIC DENTAL CLINIC
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-1732
Mailing Address - Country:US
Mailing Address - Phone:313-876-4087
Mailing Address - Fax:313-871-1589
Practice Address - Street 1:DETROIT HEALTH DEPT. - HERMAN KIEFER HEALTH COMPLEX
Practice Address - Street 2:1151 TAYLOR STREET, 7TH FLOOR PEDIATRIC DENTAL CLINIC
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-1732
Practice Address - Country:US
Practice Address - Phone:313-876-4087
Practice Address - Fax:313-871-1589
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3191980Medicaid