Provider Demographics
NPI:1316617491
Name:FOKIM, EVERAID UBANGOH (MDT)
Entity type:Individual
Prefix:
First Name:EVERAID
Middle Name:UBANGOH
Last Name:FOKIM
Suffix:
Gender:M
Credentials:MDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2312 7TH ST N
Mailing Address - Street 2:
Mailing Address - City:NORTH ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55109-2845
Mailing Address - Country:US
Mailing Address - Phone:165-180-8874
Mailing Address - Fax:
Practice Address - Street 1:9920 FOLEY BLVD NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-4579
Practice Address - Country:US
Practice Address - Phone:763-317-1166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-20
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNH10783124Q00000X
MNDT130125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125J00000XDental ProvidersDental Therapist
No124Q00000XDental ProvidersDental Hygienist