Provider Demographics
NPI:1144873944
Name:SIDHOM, FADY (DDS)
Entity type:Individual
Prefix:DR
First Name:FADY
Middle Name:
Last Name:SIDHOM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CANAL ST UNIT 621
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2054
Mailing Address - Country:US
Mailing Address - Phone:201-937-0594
Mailing Address - Fax:
Practice Address - Street 1:567 SOUTHBRIDGE ST STE 7
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:MA
Practice Address - Zip Code:01501-2256
Practice Address - Country:US
Practice Address - Phone:508-319-1480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-20
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02769200122300000X, 1223G0001X
MADN18593941223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice