Provider Demographics
NPI:1851021315
Name:IBRAHIM, MAYTHAM (DMD)
Entity Type:Individual
Prefix:DR
First Name:MAYTHAM
Middle Name:
Last Name:IBRAHIM
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 1:5669 CALHOUN ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-2235
Mailing Address - Country:US
Mailing Address - Phone:313-525-0480
Mailing Address - Fax:
Practice Address - Street 1:9550 DIX
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48120-1529
Practice Address - Country:US
Practice Address - Phone:313-438-5158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-15
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901601290122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist