Healthcare Provider Details

I. General information

NPI: 1548098908
Provider Name (Legal Business Name): ADNAN IDLIBI DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2024
Last Update Date: 07/25/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

733 TERRYVILLE AVE
BRISTOL CT
06010-4034
US

IV. Provider business mailing address

733 TERRYVILLE AVE
BRISTOL CT
06010-4034
US

V. Phone/Fax

Practice location:
  • Phone: 860-584-0441
  • Fax:
Mailing address:
  • Phone: 860-584-0441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number14180
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: