Healthcare Provider Details

I. General information

NPI: 1841126869
Provider Name (Legal Business Name): NATCHA MAHATUMARAT DDS, DSCD, CAGS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 DELAWARE ST SE STE 17-134
MINNEAPOLIS MN
55455-0357
US

IV. Provider business mailing address

255 WESTERN AVE N APT 329
SAINT PAUL MN
55102-4714
US

V. Phone/Fax

Practice location:
  • Phone: 415-815-5084
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberS250
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: