Healthcare Provider Details

I. General information

NPI: 1972111557
Provider Name (Legal Business Name): SHADY GIRGIS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2020
Last Update Date: 09/03/2020
Certification Date: 09/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1790 7TH ST E
SAINT PAUL MN
55119-3419
US

IV. Provider business mailing address

1790 7TH ST E
SAINT PAUL MN
55119-3419
US

V. Phone/Fax

Practice location:
  • Phone: 651-735-0595
  • Fax:
Mailing address:
  • Phone: 651-735-0595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD14447
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: