Provider Demographics
NPI:1871181826
Name:WAISE EBRAHIMI DDS PC
Entity Type:Organization
Organization Name:WAISE EBRAHIMI DDS PC
Other - Org Name:SMILE LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WAISE
Authorized Official - Middle Name:
Authorized Official - Last Name:EBRAHIMI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:925-548-7869
Mailing Address - Street 1:841 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-4704
Mailing Address - Country:US
Mailing Address - Phone:925-548-7869
Mailing Address - Fax:
Practice Address - Street 1:841 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-4704
Practice Address - Country:US
Practice Address - Phone:332-237-6453
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-05
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty