=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912585126
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIAM TAHIR SIDDIQUI BDS, MS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2021
-----------------------------------------------------
Last Update Date | 03/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1500 E MEDICAL CENTER DR
-----------------------------------------------------
City | ANN ARBOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48109-5000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-936-3940
-----------------------------------------------------
Fax | 734-936-3923
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18500 COUNTY ROAD 6
-----------------------------------------------------
City | PLYMOUTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55447-2531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-735-0950
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | S-167
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 2952000810
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223X2210X
-----------------------------------------------------
Taxonomy Name | Orofacial Pain Dentistry
-----------------------------------------------------
License Number | S167
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 1223X2210X
-----------------------------------------------------
Taxonomy Name | Orofacial Pain Dentistry
-----------------------------------------------------
License Number | 2952000810
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------