1609847888 NPI number — ISAM IBRAHIM, D.D.S. & ASSOCIATES (EASTWOOD MALL/NILES), INC.

Table of content: (NPI 1609847888)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609847888 NPI number — ISAM IBRAHIM, D.D.S. & ASSOCIATES (EASTWOOD MALL/NILES), INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ISAM IBRAHIM, D.D.S. & ASSOCIATES (EASTWOOD MALL/NILES), INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DENTALWORKS OF EASTWOOD NILES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609847888
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7160 DALLAS PKWY STE 400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLANO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75024-7111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5555 YOUNGSTOWN WARREN RD UNIT 908
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NILES
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44446-4810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-652-0808
Provider Business Practice Location Address Fax Number:
216-584-1071
Provider Enumeration Date:
01/27/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NITTINGER
Authorized Official First Name:
RACHEL
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER CREDENTIALING
Authorized Official Telephone Number:
972-755-0816

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223E0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: 30.021252 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0221X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223X0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)