Healthcare Provider Details

I. General information

NPI: 1720323371
Provider Name (Legal Business Name): IBRAHIM DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2012
Last Update Date: 12/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25880 TOURNAMENT RD SUITE 103
VALENCIA CA
91355-2349
US

IV. Provider business mailing address

23642 LYONS AVE #220465
NEWHALL CA
91322-6001
US

V. Phone/Fax

Practice location:
  • Phone: 661-294-3700
  • Fax: 661-294-9080
Mailing address:
  • Phone: 661-294-3700
  • Fax: 661-294-9080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number50613
License Number StateCA

VIII. Authorized Official

Name: DR. ENITAN CASSANDRA IBRAHIM
Title or Position: PRESIDENT
Credential: DDS
Phone: 661-294-3700