Provider Demographics
NPI:1720420086
Name:IBRAHIM, WALAA (BDS)
Entity Type:Individual
Prefix:
First Name:WALAA
Middle Name:
Last Name:IBRAHIM
Suffix:
Gender:F
Credentials:BDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12900 NE 180TH ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-5773
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12900 NE 180TH ST
Practice Address - Street 2:SUITE 210
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-5773
Practice Address - Country:US
Practice Address - Phone:425-485-2978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-26
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WADE60542281122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program