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General NPI Number Information
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NPI Number | 1689217341
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Entity Type | Organization
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Legal Business Name | MINT DENTAL LINO LAKES PLLC
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Dates
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Enumeration Date | 10/24/2019
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Last Update Date | 10/24/2019
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Provider Practice Location Address
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Address Line | 591 APOLLO DR
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City | CIRCLE PINES
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State | MN
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Zip | 55014-3005
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Country | US
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Telephone | 651-786-7630
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Fax |
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Provider Business Mailing Address
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Address Line | 3320 HONEYWOOD LN
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City | MINNETONKA
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State | MN
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Zip | 55305-4751
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. MARWA GAMAM-FOREST
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Credential | DDS
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Telephone | 763-300-8971
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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