Provider Demographics
NPI:1295411833
Name:IBRAHIM, ISLAM ALAA IBRAHIM MAHDY (DDS)
Entity type:Individual
Prefix:DR
First Name:ISLAM
Middle Name:ALAA IBRAHIM MAHDY
Last Name:IBRAHIM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12772 71ST ST APT 306
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-8431
Mailing Address - Country:US
Mailing Address - Phone:630-827-1120
Mailing Address - Fax:
Practice Address - Street 1:10155 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:STURTEVANT
Practice Address - State:WI
Practice Address - Zip Code:53177-1645
Practice Address - Country:US
Practice Address - Phone:262-884-3011
Practice Address - Fax:262-664-7799
Is Sole Proprietor?:No
Enumeration Date:2023-06-27
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI60012121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice