Provider Demographics
NPI:1477699130
Name:IBRAHIM, ESSAM A (DDS)
Entity Type:Individual
Prefix:
First Name:ESSAM
Middle Name:A
Last Name:IBRAHIM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14614 NEWBURGH RD
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-5742
Mailing Address - Country:US
Mailing Address - Phone:909-226-3916
Mailing Address - Fax:
Practice Address - Street 1:2585 W FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92545-4615
Practice Address - Country:US
Practice Address - Phone:951-766-5177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA468301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice