Healthcare Provider Details

I. General information

NPI: 1750051694
Provider Name (Legal Business Name): TEHMINA MANSOOR MAKHDOOM DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2021
Last Update Date: 09/13/2021
Certification Date: 09/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 HOLLAND AVE
MORGANTOWN WV
26501-4209
US

IV. Provider business mailing address

3535 SUN TRL
MORGANTOWN WV
26505-1150
US

V. Phone/Fax

Practice location:
  • Phone: 304-296-3786
  • Fax:
Mailing address:
  • Phone: 607-282-6088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4542
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: