Provider Demographics
NPI:1336818665
Name:IBRAHIM, MOSTAFA (BDS,PROSTHODONTIST)
Entity Type:Individual
Prefix:
First Name:MOSTAFA
Middle Name:
Last Name:IBRAHIM
Suffix:
Gender:M
Credentials:BDS,PROSTHODONTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CARRIAGE CITY PLZ APT 1105
Mailing Address - Street 2:
Mailing Address - City:RAHWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:07065-5185
Mailing Address - Country:US
Mailing Address - Phone:609-968-8353
Mailing Address - Fax:
Practice Address - Street 1:1 CARRIAGE CITY PLZ APT 1105
Practice Address - Street 2:
Practice Address - City:RAHWAY
Practice Address - State:NJ
Practice Address - Zip Code:07065-5185
Practice Address - Country:US
Practice Address - Phone:609-968-8353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901601119122300000X
IL019033395122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2901601119APP21Medicaid
IL019033395Medicaid