Provider Demographics
NPI:1619655917
Name:IBRAHIM, MENA (DDS)
Entity Type:Individual
Prefix:
First Name:MENA
Middle Name:
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 1:10435 KRISTEN PARK DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32832-5825
Mailing Address - Country:US
Mailing Address - Phone:407-968-5060
Mailing Address - Fax:
Practice Address - Street 1:10435 KRISTEN PARK DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32832-5825
Practice Address - Country:US
Practice Address - Phone:407-968-5060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL28348122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist