Provider Demographics
NPI:1952155236
Name:CRYSTAL CLEAR DENTAL
Entity Type:Organization
Organization Name:CRYSTAL CLEAR DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ALI
Authorized Official - Middle Name:M
Authorized Official - Last Name:IBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:210-900-4400
Mailing Address - Street 1:5507 E EVANS RD STE 105106
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78261-2023
Mailing Address - Country:US
Mailing Address - Phone:210-900-4400
Mailing Address - Fax:210-964-2260
Practice Address - Street 1:5507 E EVANS RD STE 105106
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78261-2023
Practice Address - Country:US
Practice Address - Phone:210-900-4400
Practice Address - Fax:210-964-2260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental