=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154619120
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AHMED HUSAIN SIDDIQI DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2011
-----------------------------------------------------
Last Update Date | 10/13/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12100 JEFFERSON AVE
-----------------------------------------------------
City | NEWPORT NEWS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23602-6908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-668-9275
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12108 FOREST SAGE LN
-----------------------------------------------------
City | PEARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77584-4573
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-340-0394
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 26557
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 0401417240
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------