Provider Demographics
NPI:1821776212
Name:SIDDIQI, NISSA (DMD)
Entity type:Individual
Prefix:DR
First Name:NISSA
Middle Name:
Last Name:SIDDIQI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6735 ELMCROFT CIR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-5846
Mailing Address - Country:US
Mailing Address - Phone:502-873-6377
Mailing Address - Fax:
Practice Address - Street 1:21001 SAN RAMON VALLEY BLVD STE C6
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-3456
Practice Address - Country:US
Practice Address - Phone:925-395-2786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-06
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL01980343831223G0001X
CA1108241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice