Healthcare Provider Details

I. General information

NPI: 1639259849
Provider Name (Legal Business Name): MOHAMED H IGRAM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 32ND ST NE
CEDAR RAPIDS IA
52402-4072
US

IV. Provider business mailing address

1615 32ND ST NE
CEDAR RAPIDS IA
52402-4072
US

V. Phone/Fax

Practice location:
  • Phone: 319-294-2323
  • Fax: 319-395-6715
Mailing address:
  • Phone: 319-294-2323
  • Fax: 319-395-6715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5259
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier37516
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerBLUE CROSS BLUE SHIELD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: