Healthcare Provider Details

I. General information

NPI: 1376122549
Provider Name (Legal Business Name): SIDDHARTH ACHARYA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2021
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

792 S LAPEER RD
LAKE ORION MI
48362-2922
US

IV. Provider business mailing address

20204 GOLDEN AVE
WALLED LAKE MI
48390-2560
US

V. Phone/Fax

Practice location:
  • Phone: 248-693-8366
  • Fax:
Mailing address:
  • Phone: 734-925-1196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number063778
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: