Healthcare Provider Details

I. General information

NPI: 1568074607
Provider Name (Legal Business Name): ABDULKADIR EGEH DT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2020
Last Update Date: 08/19/2020
Certification Date: 08/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

636 BROADWAY ST NE
MINNEAPOLIS MN
55413-2164
US

IV. Provider business mailing address

14430 WOODBRIDGE LN
SAVAGE MN
55378-2825
US

V. Phone/Fax

Practice location:
  • Phone: 612-746-1530
  • Fax: 612-746-1531
Mailing address:
  • Phone: 612-998-8537
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code125J00000X
TaxonomyDental Therapist
License NumberDT125
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: