Healthcare Provider Details

I. General information

NPI: 1427319763
Provider Name (Legal Business Name): MAISY IBRAHIM DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2012
Last Update Date: 06/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41990 COOK ST SUITE D402
PALM DESERT CA
92211-6100
US

IV. Provider business mailing address

41990 COOK ST SUITE D402
PALM DESERT CA
92211-6100
US

V. Phone/Fax

Practice location:
  • Phone: 760-340-0303
  • Fax: 760-346-2304
Mailing address:
  • Phone: 760-340-0303
  • Fax: 760-346-2304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number43447
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. MAISY S IBRAHIM
Title or Position: OWNER
Credential: DDS, DMD,DSM
Phone: 760-340-0303