Healthcare Provider Details

I. General information

NPI: 1376293506
Provider Name (Legal Business Name): DR. NADIMA KHODOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2022
Last Update Date: 08/25/2025
Certification Date: 08/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1290 SALEM RD SW STE 10
ROCHESTER MN
55902-4210
US

IV. Provider business mailing address

412 3RD AVE SE APT 614
ROCHESTER MN
55904-6947
US

V. Phone/Fax

Practice location:
  • Phone: 469-915-8404
  • Fax:
Mailing address:
  • Phone: 469-915-8404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number10724
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberS246
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: