Provider Demographics
NPI:1750623179
Name:SIDDIQUE, YASIR (DDS)
Entity type:Individual
Prefix:DR
First Name:YASIR
Middle Name:
Last Name:SIDDIQUE
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 1:2675 E CUMBERLAND ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19125-3727
Mailing Address - Country:US
Mailing Address - Phone:215-426-7307
Mailing Address - Fax:
Practice Address - Street 1:2675 E CUMBERLAND ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19125-3727
Practice Address - Country:US
Practice Address - Phone:215-426-7307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-24
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15297122300000X
PADS040284122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist