Provider Demographics
NPI:1154760932
Name:SALEK-RAHAM, JOHN (MD DDS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:SALEK-RAHAM
Suffix:
Gender:M
Credentials:MD DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 VILLAGE CENTER DR.
Mailing Address - Street 2:STE 170
Mailing Address - City:NORTH OAKS
Mailing Address - State:MN
Mailing Address - Zip Code:55127-3025
Mailing Address - Country:US
Mailing Address - Phone:651-482-0065
Mailing Address - Fax:651-482-6144
Practice Address - Street 1:700 VILLAGE CENTER DR.
Practice Address - Street 2:STE 170
Practice Address - City:NORTH OAKS
Practice Address - State:MN
Practice Address - Zip Code:55127-3025
Practice Address - Country:US
Practice Address - Phone:651-482-0065
Practice Address - Fax:651-482-6144
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-14
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010210111223S0112X
MNS1571223S0112X
MI4301119400204E00000X
MN67345204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery