Healthcare Provider Details

I. General information

NPI: 1265630784
Provider Name (Legal Business Name): ALFAIYAZ IBRAHIM D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2007
Last Update Date: 01/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2373 CENTRAL PARK BLVD UNIT 305
DENVER CO
80238-2301
US

IV. Provider business mailing address

2580 17TH ST UNIT 207
DENVER CO
80211-6411
US

V. Phone/Fax

Practice location:
  • Phone: 206-228-2173
  • Fax:
Mailing address:
  • Phone: 206-228-2173
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number9407
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDE00009700
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: