Healthcare Provider Details

I. General information

NPI: 1124718010
Provider Name (Legal Business Name): BRIAN IBRAHIM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2023
Last Update Date: 07/09/2025
Certification Date: 07/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11812 MOUNT EVERETT CT
RANCHO CUCAMONGA CA
91737-7925
US

IV. Provider business mailing address

11812 MOUNT EVERETT CT
RANCHO CUCAMONGA CA
91737-7925
US

V. Phone/Fax

Practice location:
  • Phone: 909-520-3976
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number111555
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: