Provider Demographics
NPI:1285180893
Name:IBANEZ, ADELINA
Entity Type:Individual
Prefix:
First Name:ADELINA
Middle Name:
Last Name:IBANEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:277 S WASHINGTON ST STE 300
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-3674
Mailing Address - Country:US
Mailing Address - Phone:571-499-5002
Mailing Address - Fax:
Practice Address - Street 1:5005 N. PIEDRAS ST. 2ND FLOOR RM 2112
Practice Address - Street 2:WILLIAM BEAUMONT ARMY MEDICAL CENTER
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79920
Practice Address - Country:US
Practice Address - Phone:915-328-2511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ199550126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant