Provider Demographics
NPI:1336163484
Name:IBRAHIM, TAYSEER AHMED
Entity Type:Individual
Prefix:
First Name:TAYSEER
Middle Name:AHMED
Last Name:IBRAHIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:II316 WADSWORTH ROAD
Mailing Address - Street 2:
Mailing Address - City:BEACH PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60099-3367
Mailing Address - Country:US
Mailing Address - Phone:847-872-5530
Mailing Address - Fax:847-872-1683
Practice Address - Street 1:11316 W WADSWORTH RD
Practice Address - Street 2:
Practice Address - City:BEACH PARK
Practice Address - State:IL
Practice Address - Zip Code:60099-3367
Practice Address - Country:US
Practice Address - Phone:847-872-5530
Practice Address - Fax:847-872-1683
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019254571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice