Provider Demographics
NPI:1427319763
Name:MAISY IBRAHIM DENTAL CORPORATION
Entity type:Organization
Organization Name:MAISY IBRAHIM DENTAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAISY
Authorized Official - Middle Name:S
Authorized Official - Last Name:IBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, DMD,DSM
Authorized Official - Phone:760-340-0303
Mailing Address - Street 1:41990 COOK ST
Mailing Address - Street 2:SUITE D402
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92211-6100
Mailing Address - Country:US
Mailing Address - Phone:760-340-0303
Mailing Address - Fax:760-346-2304
Practice Address - Street 1:41990 COOK ST
Practice Address - Street 2:SUITE D402
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92211-6100
Practice Address - Country:US
Practice Address - Phone:760-340-0303
Practice Address - Fax:760-346-2304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-04
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43447122300000X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty