Provider Demographics
NPI:1316788805
Name:ALWAN, IBRAHIM M (DDS)
Entity type:Individual
Prefix:DR
First Name:IBRAHIM
Middle Name:M
Last Name:ALWAN
Suffix:
Gender:
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 WINTHROP AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60139-2975
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:W183N9609 APPLETON AVE
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:WI
Practice Address - Zip Code:53022-4501
Practice Address - Country:US
Practice Address - Phone:262-677-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-06
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI600153615122300000X
IL019035197122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty