Provider Demographics
NPI:1285129403
Name:IBRAHIM, KAZIWA OMER (DDS)
Entity type:Individual
Prefix:
First Name:KAZIWA
Middle Name:OMER
Last Name:IBRAHIM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16486 E RADCLIFF PL APT B
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80015-7144
Mailing Address - Country:US
Mailing Address - Phone:719-761-5397
Mailing Address - Fax:
Practice Address - Street 1:16486 E RADCLIFF PL APT B
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80015-7144
Practice Address - Country:US
Practice Address - Phone:719-761-5397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-29
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.002036571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice