Provider Demographics
NPI:1770673592
Name:SIDHOM, WAGUIH AZMI (DDS)
Entity Type:Individual
Prefix:DR
First Name:WAGUIH
Middle Name:AZMI
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 1:5 KEEGANS LN
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10308-3041
Mailing Address - Country:US
Mailing Address - Phone:718-984-6181
Mailing Address - Fax:718-984-6659
Practice Address - Street 1:5 KEEGANS LN
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10308-3041
Practice Address - Country:US
Practice Address - Phone:718-984-6181
Practice Address - Fax:718-984-6659
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043273122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist