MEDICARE: MONA RIZK IBRAHIM DDS, MPH, MS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry		MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1093846974
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MONA RIZK IBRAHIM DDS, MPH, MS

Provider Business Mailing Address
First Line	:	DETROIT HEALTH DEPT. - HERMAN KIEFER HEALTH COMPLEX
Second Line	:	1151 TAYLOR STREET, 7TH FLOOR PEDIATRIC DENTAL CLINIC
City	:	DETROIT
State	:	MI
Zip	:	48202-1732
Country	:	US
Telephone Number	:	313-876-4087
Fax Number	:	313-871-1589

Provider Business Practice Location Address
First Line	:	DETROIT HEALTH DEPT. - HERMAN KIEFER HEALTH COMPLEX
Second Line	:	1151 TAYLOR STREET, 7TH FLOOR PEDIATRIC DENTAL CLINIC
City	:	DETROIT
State	:	MI
Zip	:	48202-1732
Country	:	US
Telephone Number	:	313-876-4087
Fax Number	:	313-871-1589

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2007
Last Update Date	:	07/08/2007

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