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General NPI Number Information
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NPI Number | 1447066410
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Entity Type | Organization
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Legal Business Name | IDA MED LLC
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Dates
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Enumeration Date | 12/05/2024
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Last Update Date | 12/05/2024
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Provider Practice Location Address
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Address Line | 800 W LAYTON AVE
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City | MILWAUKEE
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State | WI
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Zip | 53221-2427
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Country | US
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Telephone | 414-334-1080
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Fax |
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Provider Business Mailing Address
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Address Line | 800 W LAYTON AVE
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City | MILWAUKEE
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State | WI
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Zip | 53221-2427
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Country | US
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Telephone | 414-334-1080
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MAHMOUD ALSHARKAWI
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Credential |
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Telephone | 414-334-1080
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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