Provider Demographics
NPI:1164270641
Name:IBRAHIM, IDIRIS
Entity type:Individual
Prefix:
First Name:IDIRIS
Middle Name:
Last Name:IBRAHIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8245 AUBURN RD
Mailing Address - Street 2:
Mailing Address - City:CONCORD TOWNSHIP
Mailing Address - State:OH
Mailing Address - Zip Code:44077-9786
Mailing Address - Country:US
Mailing Address - Phone:440-856-7301
Mailing Address - Fax:
Practice Address - Street 1:8245 AUBURN RD
Practice Address - Street 2:
Practice Address - City:CONCORD TOWNSHIP
Practice Address - State:OH
Practice Address - Zip Code:44077-9786
Practice Address - Country:US
Practice Address - Phone:440-856-7301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-09
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0274881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice