Provider Demographics
NPI:1356034078
Name:ISHTIAQ, MOHAMMAD HAIDER (DDS)
Entity type:Individual
Prefix:MR
First Name:MOHAMMAD
Middle Name:HAIDER
Last Name:ISHTIAQ
Suffix:
Gender:
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 EAST 210 STREET BRONX, NEW YORK
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467
Mailing Address - Country:US
Mailing Address - Phone:718-920-4321
Mailing Address - Fax:
Practice Address - Street 1:111 EAST 210 STREET BRONX, NEW YORK
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467
Practice Address - Country:US
Practice Address - Phone:718-920-4321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-30
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY064217122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist