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General NPI Number Information
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NPI Number | 1144873944
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Entity Type | Individual
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Provider Name | FADY SIDHOM DDS
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Gender | Male
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Dates
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Enumeration Date | 07/20/2019
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Last Update Date | 07/07/2022
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Provider Practice Location Address
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Address Line | 567 SOUTHBRIDGE ST STE 7
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City | AUBURN
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State | MA
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Zip | 01501-2256
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Country | US
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Telephone | 508-319-1480
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Fax |
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Provider Business Mailing Address
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Address Line | 1 CANAL ST UNIT 621
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City | BOSTON
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State | MA
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Zip | 02114-2054
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Country | US
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Telephone | 201-937-0594
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 22DI02769200
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License Number State | NJ
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 22DI02769200
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License Number State | NJ
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Taxonomy #3
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN1859394
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License Number State | MA
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Taxonomy #4
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN1859394
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License Number State | MA
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