Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | MI |
NPI | 1093846974 |
---|---|
Provider Name | Mona Rizk Ibrahim |
First Address | Detroit, MI 48202-1732 |
Second Address | Detroit, MI 48202-1732 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/03/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
3191980 | (05) | MI |