MEDICARE: DR. YASIR SIDDIQUE DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	15297	MD
2	122300000X	Dentist	DS040284	PA

General Provider Information

NPI Number	:	1750623179
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. YASIR SIDDIQUE DDS

Provider Business Mailing Address
First Line	:	2675 E CUMBERLAND ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19125-3727
Country	:	US
Telephone Number	:	215-426-7307
Fax Number	:

Provider Business Practice Location Address
First Line	:	2675 E CUMBERLAND ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19125-3727
Country	:	US
Telephone Number	:	215-426-7307
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/24/2013
Last Update Date	:	09/10/2015

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