Provider Demographics
NPI:1205976370
Name:MARISIDDAIAH, SATISH (DDS)
Entity type:Individual
Prefix:DR
First Name:SATISH
Middle Name:
Last Name:MARISIDDAIAH
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 1:653 LONGLANE
Mailing Address - Street 2:
Mailing Address - City:UPPER DARBY
Mailing Address - State:PA
Mailing Address - Zip Code:19082
Mailing Address - Country:US
Mailing Address - Phone:610-623-5295
Mailing Address - Fax:610-623-2979
Practice Address - Street 1:653 LONG LN
Practice Address - Street 2:
Practice Address - City:UPPER DARBY
Practice Address - State:PA
Practice Address - Zip Code:19082-5230
Practice Address - Country:US
Practice Address - Phone:610-623-5295
Practice Address - Fax:610-623-2979
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS027000-L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA119271904Medicaid
PA583471OtherUCCI
PA232846078OtherEIN