Provider Demographics
NPI:1790214856
Name:JADUN, IBRAHIM (DMD)
Entity Type:Individual
Prefix:DR
First Name:IBRAHIM
Middle Name:
Last Name:JADUN
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 1:2471 SW 82ND AVE APT 309
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33324-5776
Mailing Address - Country:US
Mailing Address - Phone:330-503-7399
Mailing Address - Fax:
Practice Address - Street 1:15148 N DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-1817
Practice Address - Country:US
Practice Address - Phone:813-960-0106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-12
Last Update Date:2017-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN226381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice