Healthcare Provider Details

I. General information

NPI: 1144029778
Provider Name (Legal Business Name): MHD FAROUK ALSHATTI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2025
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3410 DOUGLAS RD
SOUTH BEND IN
46635-1776
US

IV. Provider business mailing address

515 DELAWARE ST SE
MINNEAPOLIS MN
55455-0357
US

V. Phone/Fax

Practice location:
  • Phone: 574-234-4117
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12014972A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: