Healthcare Provider Details

I. General information

NPI: 1205649167
Provider Name (Legal Business Name): KHIZAR KHALID SIDDIQUI DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2025
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 BENEFIT ST
PROVIDENCE RI
02904-2762
US

IV. Provider business mailing address

635 ALBANY ST
BOSTON MA
02118-3550
US

V. Phone/Fax

Practice location:
  • Phone: 401-521-3822
  • Fax:
Mailing address:
  • Phone: 617-358-8300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDEN03883
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN10001547
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: