Provider Demographics
NPI:1255074373
Name:IBRAHIM, PETER (DMD)
Entity type:Individual
Prefix:DR
First Name:PETER
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 1:7548 BRIGHTWATER PL
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-5648
Mailing Address - Country:US
Mailing Address - Phone:321-276-8465
Mailing Address - Fax:
Practice Address - Street 1:249 PALM BAY RD NE
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-8602
Practice Address - Country:US
Practice Address - Phone:321-482-5220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-16
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN270811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice