Provider Demographics
NPI:1982488268
Name:KHALIL, MD IBRAHIM (DDS)
Entity type:Individual
Prefix:
First Name:MD
Middle Name:IBRAHIM
Last Name:KHALIL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7610 ELK GROVE BLVD
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95757-6493
Mailing Address - Country:US
Mailing Address - Phone:209-235-0295
Mailing Address - Fax:
Practice Address - Street 1:7860 WEST LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-2758
Practice Address - Country:US
Practice Address - Phone:209-235-0295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-18
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA109125122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist