Provider Demographics
NPI:1720323371
Name:IBRAHIM DENTAL CORPORATION
Entity Type:Organization
Organization Name:IBRAHIM DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ENITAN
Authorized Official - Middle Name:CASSANDRA
Authorized Official - Last Name:IBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:661-294-3700
Mailing Address - Street 1:23642 LYONS AVE
Mailing Address - Street 2:#220465
Mailing Address - City:NEWHALL
Mailing Address - State:CA
Mailing Address - Zip Code:91322-6001
Mailing Address - Country:US
Mailing Address - Phone:661-294-3700
Mailing Address - Fax:661-294-9080
Practice Address - Street 1:25880 TOURNAMENT RD
Practice Address - Street 2:SUITE 103
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-2349
Practice Address - Country:US
Practice Address - Phone:661-294-3700
Practice Address - Fax:661-294-9080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-09
Last Update Date:2012-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50613261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental