Healthcare Provider Details

I. General information

NPI: 1831022508
Provider Name (Legal Business Name): IBRAM SAMUEL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2026
Last Update Date: 06/04/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4550 EUBANK BLVD NE STE 101
ALBUQUERQUE NM
87111-2565
US

IV. Provider business mailing address

4550 EUBANK BLVD NE STE 101
ALBUQUERQUE NM
87111-2565
US

V. Phone/Fax

Practice location:
  • Phone: 505-292-8588
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDB-2026-0184
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: