Provider Demographics
NPI:1164110623
Name:AL-JERDI, IBRAHIM A (DDS)
Entity Type:Individual
Prefix:
First Name:IBRAHIM
Middle Name:A
Last Name:AL-JERDI
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 1:20818 E RIVER RD
Mailing Address - Street 2:
Mailing Address - City:GROSSE ILE
Mailing Address - State:MI
Mailing Address - Zip Code:48138-1165
Mailing Address - Country:US
Mailing Address - Phone:734-931-2484
Mailing Address - Fax:
Practice Address - Street 1:1640 FORT ST
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MI
Practice Address - Zip Code:48183-2040
Practice Address - Country:US
Practice Address - Phone:734-675-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-24
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29016017031223G0001X
MI390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes1223G0001XDental ProvidersDentistGeneral Practice