Provider Demographics
NPI:1679259246
Name:SIDDIQUI, MOHAMMAD T (DDS)
Entity type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:T
Last Name:SIDDIQUI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3654 WILTSHIRE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-2956
Mailing Address - Country:US
Mailing Address - Phone:734-262-0909
Mailing Address - Fax:
Practice Address - Street 1:23800 ORCHARD LAKE RD STE 106
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-2561
Practice Address - Country:US
Practice Address - Phone:248-755-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-27
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI29016023651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program