Provider Demographics
NPI:1750641833
Name:SIDDIQUA, MIR AYESHA (DDS)
Entity Type:Individual
Prefix:
First Name:MIR AYESHA
Middle Name:
Last Name:SIDDIQUA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:AYESHA
Other - Middle Name:MIR
Other - Last Name:SIDDIQUA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:311 DORIC AVE
Mailing Address - Street 2:311 DORIC AVENUE
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02910-2903
Mailing Address - Country:US
Mailing Address - Phone:401-562-8303
Mailing Address - Fax:
Practice Address - Street 1:311 DORIC AVE
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02910-2903
Practice Address - Country:US
Practice Address - Phone:401-562-8303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-22
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SC81981223G0001X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery