Provider Demographics
NPI:1689149775
Name:MINT DENTAL SHAKOPEE PLLC
Entity Type:Organization
Organization Name:MINT DENTAL SHAKOPEE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARWA
Authorized Official - Middle Name:
Authorized Official - Last Name:GAMAM-FOREST
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-831-1332
Mailing Address - Street 1:205 LEWIS ST S STE 101
Mailing Address - Street 2:
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-2290
Mailing Address - Country:US
Mailing Address - Phone:952-445-3349
Mailing Address - Fax:
Practice Address - Street 1:205 LEWIS ST S STE 101
Practice Address - Street 2:
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-2290
Practice Address - Country:US
Practice Address - Phone:952-445-3349
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-04
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental