Healthcare Provider Details

I. General information

NPI: 1730679325
Provider Name (Legal Business Name): NADINE YACOUB DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2018
Last Update Date: 09/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3930 NORTHWOODS DR
ARDEN HILLS MN
55112
US

IV. Provider business mailing address

3930 NORTHWOODS DR
ARDEN HILLS MN
55112-6963
US

V. Phone/Fax

Practice location:
  • Phone: 651-523-8585
  • Fax:
Mailing address:
  • Phone: 651-523-8585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD14016
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: