Provider Demographics
NPI:1942661582
Name:IBRAHIM, SARA (DDS)
Entity Type:Individual
Prefix:DR
First Name:SARA
Middle Name:
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 1:5240 DUKE ST APT 109
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-2952
Mailing Address - Country:US
Mailing Address - Phone:304-419-5231
Mailing Address - Fax:
Practice Address - Street 1:2333 N 6TH ST
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-2001
Practice Address - Country:US
Practice Address - Phone:970-255-1782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-09
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA04014157561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program