Provider Demographics
NPI:1356463582
Name:MIRZA, SIKANDER HAYAT (DDS)
Entity Type:Individual
Prefix:
First Name:SIKANDER
Middle Name:HAYAT
Last Name:MIRZA
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:PO BOX 2557
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12402-2557
Mailing Address - Country:US
Mailing Address - Phone:845-339-2414
Mailing Address - Fax:845-339-2415
Practice Address - Street 1:622 BROAD WAY
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12402-2557
Practice Address - Country:US
Practice Address - Phone:845-339-2414
Practice Address - Fax:845-339-2415
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04124311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01054475Medicaid