Provider Demographics
NPI:1417094962
Name:IBANEZ-PABON, JOSE ENRIQUE (DMD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:ENRIQUE
Last Name:IBANEZ-PABON
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 1:5483 ASHLEIGH RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-7269
Mailing Address - Country:US
Mailing Address - Phone:703-681-6464
Mailing Address - Fax:703-681-6152
Practice Address - Street 1:238 BROOKLEY AVE
Practice Address - Street 2:
Practice Address - City:BOLLING AFB
Practice Address - State:DC
Practice Address - Zip Code:20332-0701
Practice Address - Country:US
Practice Address - Phone:202-767-5382
Practice Address - Fax:202-767-4091
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH211791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice