Provider Demographics
NPI:1376293506
Name:KHODOR, NADIMA
Entity type:Individual
Prefix:DR
First Name:NADIMA
Middle Name:
Last Name:KHODOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 3RD AVE SE APT 614
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55904-6947
Mailing Address - Country:US
Mailing Address - Phone:469-915-8404
Mailing Address - Fax:
Practice Address - Street 1:1290 SALEM RD SW STE 10
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55902-4210
Practice Address - Country:US
Practice Address - Phone:469-915-8404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-29
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY10724122300000X
MNS246122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist