=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679259246
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOHAMMAD T SIDDIQUI DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2023
-----------------------------------------------------
Last Update Date | 09/24/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23800 ORCHARD LAKE RD STE 106
-----------------------------------------------------
City | FARMINGTON HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48336-2561
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-755-5700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3654 WILTSHIRE
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48188-2956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-262-0909
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 2901602365
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------