Provider Demographics
NPI:1679959639
Name:SIDHOM, MAHA (DMD)
Entity type:Individual
Prefix:DR
First Name:MAHA
Middle Name:
Last Name:SIDHOM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80113-3611
Mailing Address - Country:US
Mailing Address - Phone:303-360-6276
Mailing Address - Fax:
Practice Address - Street 1:7495 W 29TH AVE
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-8002
Practice Address - Country:US
Practice Address - Phone:303-360-6276
Practice Address - Fax:303-237-4343
Is Sole Proprietor?:No
Enumeration Date:2015-07-31
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00202623122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist