Provider Demographics
NPI:1174616817
Name:FAKHREDDINE, KAMAL MOHAMAD (DDS)
Entity type:Individual
Prefix:
First Name:KAMAL
Middle Name:MOHAMAD
Last Name:FAKHREDDINE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2006 1ST AVENUE NORTH
Mailing Address - Street 2:STE 202
Mailing Address - City:ANOKA
Mailing Address - State:MN
Mailing Address - Zip Code:55303
Mailing Address - Country:US
Mailing Address - Phone:763-427-7930
Mailing Address - Fax:763-427-7537
Practice Address - Street 1:2006 1ST AVENUE NORTH
Practice Address - Street 2:STE 202
Practice Address - City:ANOKA
Practice Address - State:MN
Practice Address - Zip Code:55303
Practice Address - Country:US
Practice Address - Phone:763-427-7930
Practice Address - Fax:763-427-7537
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN110081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice