Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 2901600262 | MI |
NPI | 1104307651 |
---|---|
Provider Name | Dr. Fahad Siddiqui |
First Address | Dearborn, MI 48126-2672 |
Second Address | Detroit, MI 48208-2576 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/08/2018 |
Last Update Date | 04/11/2019 |