Provider Demographics
NPI:1376122549
Name:ACHARYA, SIDDHARTH
Entity Type:Individual
Prefix:
First Name:SIDDHARTH
Middle Name:
Last Name:ACHARYA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1616 DELANCY CIR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-8503
Mailing Address - Country:US
Mailing Address - Phone:734-925-1196
Mailing Address - Fax:
Practice Address - Street 1:29 WASHINGTON SQ W APT 1C
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-9132
Practice Address - Country:US
Practice Address - Phone:212-777-1181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-05
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY0637781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program