Provider Demographics
NPI:1912585126
Name:SIDDIQUI, MARIAM TAHIR (BDS, MS)
Entity Type:Individual
Prefix:
First Name:MARIAM
Middle Name:TAHIR
Last Name:SIDDIQUI
Suffix:
Gender:F
Credentials:BDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18500 COUNTY ROAD 6
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-2531
Mailing Address - Country:US
Mailing Address - Phone:612-735-0950
Mailing Address - Fax:
Practice Address - Street 1:1500 E MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-5000
Practice Address - Country:US
Practice Address - Phone:763-936-3940
Practice Address - Fax:734-936-3923
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-30
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNS-1671223S0112X
MI29520008101223S0112X, 1223X2210X
MNS1671223X2210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X2210XDental ProvidersDentistOrofacial Pain
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty