Healthcare Provider Details

I. General information

NPI: 1376569012
Provider Name (Legal Business Name): AMMAR IDLIBI D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 10/14/2008
Certification Date:
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: 860-516-8918
Mailing address:
  • Phone: 860-584-0441
  • Fax: 860-516-8918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberP07893
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberPO7893
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: