Provider Demographics
NPI:1114410503
Name:IQBAL, SIDRA
Entity Type:Individual
Prefix:
First Name:SIDRA
Middle Name:
Last Name:IQBAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4811 LIKINS CIR
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-4200
Mailing Address - Country:US
Mailing Address - Phone:978-728-2351
Mailing Address - Fax:
Practice Address - Street 1:3711 GREGORY ST
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-1614
Practice Address - Country:US
Practice Address - Phone:978-728-2351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-11
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX339381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice