Provider Demographics
NPI:1356055628
Name:MALIK, IBRAHIM HUSHAM (DDS)
Entity type:Individual
Prefix:
First Name:IBRAHIM
Middle Name:HUSHAM
Last Name:MALIK
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 1:1323 LAWSON LN
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-3639
Mailing Address - Country:US
Mailing Address - Phone:571-275-8037
Mailing Address - Fax:
Practice Address - Street 1:30123 RANCHO CALIFORNIA RD APT 634
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-5493
Practice Address - Country:US
Practice Address - Phone:571-275-8037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA108466122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist