Healthcare Provider Details

I. General information

NPI: 1336988195
Provider Name (Legal Business Name): MARIAM IBRAHIM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2024
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2614 E MADISON DR
ATLANTA GA
30360-2027
US

IV. Provider business mailing address

2614 E MADISON DR
ATLANTA GA
30360-2027
US

V. Phone/Fax

Practice location:
  • Phone: 770-906-0780
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN123616
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: