Basic Information
| Provider Information | |||||||||
| NPI: | 1245691757 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IBRAHIMKHIL | ||||||||
| FirstName: | MASTORA | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 163 FORT EVANS RD NE | ||||||||
| Address2: | |||||||||
| City: | LEESBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201764420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7034432000 | ||||||||
| FaxNumber: | 7037714120 | ||||||||
| Practice Location | |||||||||
| Address1: | 163 FORT EVANS RD NE | ||||||||
| Address2: | |||||||||
| City: | LEESBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201764420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7034432000 | ||||||||
| FaxNumber: | 7037714120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2016 | ||||||||
| LastUpdateDate: | 03/10/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | 0402202407 | VA | Y | Dental Providers | Dental Hygienist |
ID Information
| ID | Type | State | Issuer | Description | VIRGINIA | 05 | VA | MEDICAID |