Healthcare Provider Details

I. General information

NPI: 1487271615
Provider Name (Legal Business Name): BILAL IBRAHIM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2020
Last Update Date: 09/02/2025
Certification Date: 09/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 SAINT ANTOINE ST
DETROIT MI
48201-2153
US

IV. Provider business mailing address

6475 KENILWORTH ST
DEARBORN MI
48126-2158
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-4697
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number021.003447
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2901600887
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: