Provider Demographics
NPI:1376569012
Name:IDLIBI, AMMAR (DMD)
Entity Type:Individual
Prefix:
First Name:AMMAR
Middle Name:
Last Name:IDLIBI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:733 TERRYVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-4034
Mailing Address - Country:US
Mailing Address - Phone:860-584-0441
Mailing Address - Fax:860-516-8918
Practice Address - Street 1:733 TERRYVILLE AVE
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-4034
Practice Address - Country:US
Practice Address - Phone:860-584-0441
Practice Address - Fax:860-516-8918
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CTP078931223P0221X
CTPO78931223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics