Healthcare Provider Details

I. General information

NPI: 1225873912
Provider Name (Legal Business Name): NICHOLAS IBRAHIM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2024
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6315 COMMERCE BLVD
ROHNERT PARK CA
94928-2403
US

IV. Provider business mailing address

1806 ALAN DR
PENNGROVE CA
94951-9735
US

V. Phone/Fax

Practice location:
  • Phone: 707-548-7401
  • Fax:
Mailing address:
  • Phone: 650-464-9201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDDS113238
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: