Provider Demographics
NPI:1629755087
Name:SIM, MINGI NICOLE
Entity type:Individual
Prefix:
First Name:MINGI
Middle Name:NICOLE
Last Name:SIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIN GI
Other - Middle Name:
Other - Last Name:SIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-2524
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 BROAD ST
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-2524
Practice Address - Country:US
Practice Address - Phone:973-744-7003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-28
Last Update Date:2025-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY064658011223G0001X
NJ22DI031075001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice