Provider Demographics
NPI:1417570409
Name:IRFAN, SIDRA (DDS)
Entity Type:Individual
Prefix:
First Name:SIDRA
Middle Name:
Last Name:IRFAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:SIDRA
Other - Middle Name:
Other - Last Name:IRFAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:1966 E 82ND ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44103-4238
Mailing Address - Country:US
Mailing Address - Phone:607-857-7708
Mailing Address - Fax:
Practice Address - Street 1:39883 FORD RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-4319
Practice Address - Country:US
Practice Address - Phone:734-456-3155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-25
Last Update Date:2021-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI2901601104122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program