Healthcare Provider Details

I. General information

NPI: 1043454135
Provider Name (Legal Business Name): IDRISS MOBARAK INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2009
Last Update Date: 04/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7809 LOUETTA RD
SPRING TX
77379-7007
US

IV. Provider business mailing address

7809 LOUETTA RD
SPRING TX
77379-7007
US

V. Phone/Fax

Practice location:
  • Phone: 281-257-8815
  • Fax: 281-257-6267
Mailing address:
  • Phone: 281-257-8815
  • Fax: 281-257-6267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number17900
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number17900
License Number StateTX

VIII. Authorized Official

Name: DR. MAISA IDRISS
Title or Position: OWNER
Credential: DMD
Phone: 281-257-8815