MEDICARE: DR. ILAF AL MAWALDI DDS

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	0401415557	VA

General Provider Information

NPI Number	:	1346760915
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ILAF AL MAWALDI DDS

Provider Business Mailing Address
First Line	:	465 BRANTWOOD RD
Second Line	:
City	:	BUFFALO
State	:	NY
Zip	:	14226-4641
Country	:	US
Telephone Number	:	716-866-7011
Fax Number	:

Provider Business Practice Location Address
First Line	:	2065 S PLEASANT VALLEY RD
Second Line	:
City	:	WINCHESTER
State	:	VA
Zip	:	22601-7001
Country	:	US
Telephone Number	:	716-866-7011
Fax Number	:

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

Provider Enumeration Date	:	06/23/2017
Last Update Date	:	06/23/2017

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