Basic Information
| Provider Information | |||||||||
| NPI: | 1265861801 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IBRAHIM | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 CHESTNUT PL APT 810 | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021695388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096364534 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1810 WASHINGTON ST STE 3&4 | ||||||||
| Address2: | |||||||||
| City: | HANOVER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023391685 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516773078 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2013 | ||||||||
| LastUpdateDate: | 03/29/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 62453 | CA | N | Dental Providers | Dentist | General Practice | 122300000X | DN1859150 | MA | Y | Dental Providers | Dentist |
No ID Information.