Provider Demographics
NPI:1710021969
Name:IBRAHIM, SAMY ALY MOHAMED (DDS)
Entity type:Individual
Prefix:DR
First Name:SAMY
Middle Name:ALY MOHAMED
Last Name:IBRAHIM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:166 N MOORPARK RD
Mailing Address - Street 2:SUITE 302
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-4405
Mailing Address - Country:US
Mailing Address - Phone:805-497-7366
Mailing Address - Fax:805-497-0638
Practice Address - Street 1:166 N MOORPARK RD
Practice Address - Street 2:SUITE 302
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-4405
Practice Address - Country:US
Practice Address - Phone:805-497-7366
Practice Address - Fax:805-497-0638
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA398151223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics