Provider Demographics
NPI:1689217341
Name:MINT DENTAL LINO LAKES PLLC
Entity Type:Organization
Organization Name:MINT DENTAL LINO LAKES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
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:763-300-8971
Mailing Address - Street 1:3320 HONEYWOOD LN
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-4751
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:591 APOLLO DR
Practice Address - Street 2:
Practice Address - City:CIRCLE PINES
Practice Address - State:MN
Practice Address - Zip Code:55014-3005
Practice Address - Country:US
Practice Address - Phone:651-786-7630
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-24
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental