Provider Demographics
NPI:1235356635
Name:TAYSEER A IBRAHIM DDS PC
Entity Type:Organization
Organization Name:TAYSEER A IBRAHIM DDS PC
Other - Org Name:WADSWORTH DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAYSEER
Authorized Official - Middle Name:AHMED
Authorized Official - Last Name:IBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-872-5530
Mailing Address - Street 1:11316 W WADSWORTH RD
Mailing Address - Street 2:
Mailing Address - City:BEACH PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60099-3367
Mailing Address - Country:US
Mailing Address - Phone:847-872-5530
Mailing Address - Fax:847-872-1683
Practice Address - Street 1:11316 W WADSWORTH RD
Practice Address - Street 2:
Practice Address - City:BEACH PARK
Practice Address - State:IL
Practice Address - Zip Code:60099-3367
Practice Address - Country:US
Practice Address - Phone:847-872-5530
Practice Address - Fax:847-872-1683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL01925457122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty