Healthcare Provider Details

I. General information

NPI: 1629755087
Provider Name (Legal Business Name): MINGI NICOLE SIM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MIN GI SIM

II. Dates (important events)

Enumeration Date: 06/28/2023
Last Update Date: 09/17/2025
Certification Date: 09/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 BROAD ST
BLOOMFIELD NJ
07003-2524
US

IV. Provider business mailing address

10 BROAD ST
BLOOMFIELD NJ
07003-2524
US

V. Phone/Fax

Practice location:
  • Phone: 973-744-7003
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number06465801
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22DI03107500
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: