=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124458609
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FATIMA A TIWANA BDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2013
-----------------------------------------------------
Last Update Date | 05/10/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8515 EAGLE POINT BLVD STE 200
-----------------------------------------------------
City | LAKE ELMO
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55042-8624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-523-9950
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8515 EAGLE POINT BLVD STE 200
-----------------------------------------------------
City | LAKE ELMO
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55042-8624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-523-9950
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 2901020871
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------