Provider Demographics
NPI:1316609373
Name:IBRAHIM, MOSTAFA JALEEL
Entity type:Individual
Prefix:
First Name:MOSTAFA
Middle Name:JALEEL
Last Name:IBRAHIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER EL PASO
Mailing Address - Street 2:137 RICK FRANCIS ST. MSB II, ROOM 3B306
Mailing Address - City:ELPASO
Mailing Address - State:TX
Mailing Address - Zip Code:79905
Mailing Address - Country:US
Mailing Address - Phone:915-215-5319
Mailing Address - Fax:
Practice Address - Street 1:TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER EL PASO
Practice Address - Street 2:137 RICK FRANCIS ST. MSB II, ROOM 3B306
Practice Address - City:ELPASO
Practice Address - State:TX
Practice Address - Zip Code:79905
Practice Address - Country:US
Practice Address - Phone:915-215-5319
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX378881223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics