Provider Demographics
NPI:1043454135
Name:IDRISS MOBARAK INC.
Entity type:Organization
Organization Name:IDRISS MOBARAK INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAISA
Authorized Official - Middle Name:
Authorized Official - Last Name:IDRISS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:281-257-8815
Mailing Address - Street 1:7809 LOUETTA RD
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77379-7007
Mailing Address - Country:US
Mailing Address - Phone:281-257-8815
Mailing Address - Fax:281-257-6267
Practice Address - Street 1:7809 LOUETTA RD
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77379-7007
Practice Address - Country:US
Practice Address - Phone:281-257-8815
Practice Address - Fax:281-257-6267
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IDRISS MOBARAK INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-21
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
122300000X, 1223P0700X, 1223S0112X
TX17900122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty