=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336818665
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOSTAFA IBRAHIM BDS,PROSTHODONTIST
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2021
-----------------------------------------------------
Last Update Date | 09/09/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 CARRIAGE CITY PLZ APT 1105
-----------------------------------------------------
City | RAHWAY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07065-5185
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-968-8353
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 CARRIAGE CITY PLZ APT 1105
-----------------------------------------------------
City | RAHWAY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07065-5185
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-968-8353
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 2901601119
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 019033395
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------