Provider Demographics
NPI:1558937979
Name:AL KHAFAJI, IBRAHEEM THABIT HASSOON (DDS)
Entity Type:Individual
Prefix:
First Name:IBRAHEEM
Middle Name:THABIT HASSOON
Last Name:AL KHAFAJI
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 1:6501 S FRY RD STE 800
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77494-3802
Mailing Address - Country:US
Mailing Address - Phone:708-717-9213
Mailing Address - Fax:
Practice Address - Street 1:6501 S FRY RD STE 800
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77494-3802
Practice Address - Country:US
Practice Address - Phone:708-717-9213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-27
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND14547122300000X
TX381261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist