Provider Demographics
NPI:1407372550
Name:IBRAHIM, SANDY N (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:SANDY
Middle Name:N
Last Name:IBRAHIM
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1883 RANCHO TUJUNGA DR
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91724-3546
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12223 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91739-2574
Practice Address - Country:US
Practice Address - Phone:909-463-7890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-21
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS101828122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADDS1010828Medicaid