Provider Demographics
NPI:1568074607
Name:EGEH, ABDULKADIR (DT)
Entity Type:Individual
Prefix:
First Name:ABDULKADIR
Middle Name:
Last Name:EGEH
Suffix:
Gender:M
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14430 WOODBRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:SAVAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55378-2825
Mailing Address - Country:US
Mailing Address - Phone:612-998-8537
Mailing Address - Fax:
Practice Address - Street 1:636 BROADWAY ST NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413-2164
Practice Address - Country:US
Practice Address - Phone:612-746-1530
Practice Address - Fax:612-746-1531
Is Sole Proprietor?:No
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNDT125125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125J00000XDental ProvidersDental Therapist