Provider Demographics
NPI:1508597873
Name:ABUSHEHAB, WALA (DDS)
Entity Type:Individual
Prefix:DR
First Name:WALA
Middle Name:
Last Name:ABUSHEHAB
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2949 4TH ST SE UNIT 335
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-3899
Mailing Address - Country:US
Mailing Address - Phone:810-498-5717
Mailing Address - Fax:
Practice Address - Street 1:13040 RIVERDALE DR NW STE 600
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55448-8419
Practice Address - Country:US
Practice Address - Phone:763-323-3042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-18
Last Update Date:2022-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN00000001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice