Healthcare Provider Details

I. General information

NPI: 1316617491
Provider Name (Legal Business Name): EVERAID UBANGOH FOKIM MDT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2021
Last Update Date: 09/20/2021
Certification Date: 09/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9920 FOLEY BLVD NW
COON RAPIDS MN
55433-4579
US

IV. Provider business mailing address

2312 7TH ST N
NORTH ST PAUL MN
55109-2845
US

V. Phone/Fax

Practice location:
  • Phone: 763-317-1166
  • Fax:
Mailing address:
  • Phone: 165-180-8874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH10783
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code125J00000X
TaxonomyDental Therapist
License NumberDT130
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: