Healthcare Provider Details

I. General information

NPI: 1619601820
Provider Name (Legal Business Name): SIMIL TAMSEEL FATIMA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2022
Last Update Date: 07/13/2022
Certification Date: 07/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10210 BALTIMORE ST NE STE 100
BLAINE MN
55449-6050
US

IV. Provider business mailing address

10210 BALTIMORE ST NE STE 100
BLAINE MN
55449-6050
US

V. Phone/Fax

Practice location:
  • Phone: 763-231-2050
  • Fax: 763-231-2052
Mailing address:
  • Phone: 763-231-2050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD14807
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: