Provider Demographics
NPI:1265861801
Name:IBRAHIM, GEORGE (DMD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:
Last Name:IBRAHIM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CHESTNUT PL APT 810
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-5388
Mailing Address - Country:US
Mailing Address - Phone:909-636-4534
Mailing Address - Fax:
Practice Address - Street 1:1810 WASHINGTON ST STE 3&4
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:MA
Practice Address - Zip Code:02339-1685
Practice Address - Country:US
Practice Address - Phone:951-677-3078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-04
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA624531223G0001X
MADN1859150122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice