Provider Demographics
NPI:1568194322
Name:ELGUMATI, IBRAHIM (DMD)
Entity Type:Individual
Prefix:DR
First Name:IBRAHIM
Middle Name:
Last Name:ELGUMATI
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 1:4336 WATERSTONE LN
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40515-6017
Mailing Address - Country:US
Mailing Address - Phone:859-806-3052
Mailing Address - Fax:
Practice Address - Street 1:2710 ALEXANDRIA PIKE
Practice Address - Street 2:
Practice Address - City:HIGHLAND HEIGHTS
Practice Address - State:KY
Practice Address - Zip Code:41076-1510
Practice Address - Country:US
Practice Address - Phone:859-781-3090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-29
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY10824122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist