Provider Demographics
NPI:1619010840
Name:IBRAHIM, MAISY S (DDS)
Entity Type:Individual
Prefix:MRS
First Name:MAISY
Middle Name:S
Last Name:IBRAHIM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41990 COOK STREET
Mailing Address - Street 2:D 402
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92211
Mailing Address - Country:US
Mailing Address - Phone:760-340-0303
Mailing Address - Fax:760-346-2304
Practice Address - Street 1:41990 COOK ST
Practice Address - Street 2:D 402
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92211-6100
Practice Address - Country:US
Practice Address - Phone:760-340-0303
Practice Address - Fax:760-346-2304
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA434471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice