MEDICARE: DR. WAGUIH AZMI SIDHOM DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	043273	NY

General Provider Information

NPI Number	:	1770673592
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WAGUIH AZMI SIDHOM DDS

Provider Business Mailing Address
First Line	:	5 KEEGANS LN
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10308-3041
Country	:	US
Telephone Number	:	718-984-6181
Fax Number	:	718-984-6659

Provider Business Practice Location Address
First Line	:	5 KEEGANS LN
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10308-3041
Country	:	US
Telephone Number	:	718-984-6181
Fax Number	:	718-984-6659

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/13/2006
Last Update Date	:	07/08/2007

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