Healthcare Provider Details

I. General information

NPI: 1669805057
Provider Name (Legal Business Name): SYRAH IMTIAZ QURAISHI DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2013
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8860 ZIONSVILLE RD STE B
INDIANAPOLIS IN
46268-1061
US

IV. Provider business mailing address

8860 ZIONSVILLE RD STE B SUITE B
INDIANAPOLIS IN
46268-1061
US

V. Phone/Fax

Practice location:
  • Phone: 317-672-2759
  • Fax: 317-735-1241
Mailing address:
  • Phone: 317-672-2759
  • Fax: 317-735-1241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number7111-15
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number12012422A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: