Provider Demographics
NPI:1598834616
Name:MASSOUD, IBRAHIM (DDS)
Entity Type:Individual
Prefix:
First Name:IBRAHIM
Middle Name:
Last Name:MASSOUD
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 1:2743 S 6TH STREET
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703
Mailing Address - Country:US
Mailing Address - Phone:217-522-4121
Mailing Address - Fax:217-522-7140
Practice Address - Street 1:2743 S 6TH STREET
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703
Practice Address - Country:US
Practice Address - Phone:217-522-4121
Practice Address - Fax:217-522-7140
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILO19025844122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist