Healthcare Provider Details

I. General information

NPI: 1134708217
Provider Name (Legal Business Name): TAMER MARZOUK BDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2021
Last Update Date: 03/29/2024
Certification Date: 03/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 S 8TH ST
MINNEAPOLIS MN
55404
US

IV. Provider business mailing address

701 PARK AVE
MINNEAPOLIS MN
55415-1623
US

V. Phone/Fax

Practice location:
  • Phone: 612-873-6963
  • Fax:
Mailing address:
  • Phone: 612-873-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberFF90
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: