Provider Demographics
NPI:1447066410
Name:IDA MED LLC
Entity type:Organization
Organization Name:IDA MED LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAHMOUD
Authorized Official - Middle Name:
Authorized Official - Last Name:ALSHARKAWI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-334-1080
Mailing Address - Street 1:800 W LAYTON AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53221-2427
Mailing Address - Country:US
Mailing Address - Phone:414-334-1080
Mailing Address - Fax:
Practice Address - Street 1:800 W LAYTON AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53221-2427
Practice Address - Country:US
Practice Address - Phone:414-334-1080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EXCEL DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-12-05
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty