Provider Demographics
NPI:1104834316
Name:JARJOURA, IBRAHIM F (DDS)
Entity Type:Individual
Prefix:
First Name:IBRAHIM
Middle Name:F
Last Name:JARJOURA
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 1:8189 S SAGINAW ST STE A
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-1825
Mailing Address - Country:US
Mailing Address - Phone:810-695-1151
Mailing Address - Fax:810-695-2086
Practice Address - Street 1:8189 S SAGINAW ST STE A
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-1825
Practice Address - Country:US
Practice Address - Phone:810-695-1151
Practice Address - Fax:810-695-2086
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MID1481801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice