Healthcare Provider Details

I. General information

NPI: 1831875301
Provider Name (Legal Business Name): IBRAHIM KHATIB DDS, MPROS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2023
Last Update Date: 06/27/2023
Certification Date: 06/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 W WISCONSIN AVE OFC 327
MILWAUKEE WI
53233-2186
US

IV. Provider business mailing address

5805 N LYDELL AVE #308
GLENDALE WI
53217
US

V. Phone/Fax

Practice location:
  • Phone: 414-288-6047
  • Fax:
Mailing address:
  • Phone: 262-227-5585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number23475-875
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: