Healthcare Provider Details

I. General information

NPI: 1154310845
Provider Name (Legal Business Name): IBRAHIM A DURRA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 10/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 W CHESTER PIKE
HAVERTOWN PA
19083-3339
US

IV. Provider business mailing address

1220 W CHESTER PIKE
HAVERTOWN PA
19083-3339
US

V. Phone/Fax

Practice location:
  • Phone: 484-454-3230
  • Fax: 484-455-7186
Mailing address:
  • Phone: 484-454-3230
  • Fax: 484-455-7186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDS035913L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: