Healthcare Provider Details

I. General information

NPI: 1952841017
Provider Name (Legal Business Name): TAYEBA MINHAS IKRAM D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2017
Last Update Date: 03/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 STONECREST CT SUITE NUMBER 200
SHELBYVILLE KY
40065-8155
US

IV. Provider business mailing address

2003 ASHFORD DR
GOSHEN KY
40026-8424
US

V. Phone/Fax

Practice location:
  • Phone: 502-633-1819
  • Fax:
Mailing address:
  • Phone: 812-989-3459
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number9880
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: