=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669544862
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ENITAN C. IBRAHIM DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2006
-----------------------------------------------------
Last Update Date | 04/30/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27947 SLOAN CANYON RD
-----------------------------------------------------
City | CASTAIC
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91384-2594
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-294-3700
-----------------------------------------------------
Fax | 661-294-9080
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27947 SLOAN CANYON RD
-----------------------------------------------------
City | CASTAIC
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91384-2594
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-294-3700
-----------------------------------------------------
Fax | 661-294-9080
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 50613
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------