Provider Demographics
NPI:1124120381
Name:SIDDIQUE, MUMTAZ AHMED (DDS)
Entity type:Individual
Prefix:DR
First Name:MUMTAZ
Middle Name:AHMED
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 1:552 N MCLEAN BLVD
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123
Mailing Address - Country:US
Mailing Address - Phone:847-931-9744
Mailing Address - Fax:847-931-7726
Practice Address - Street 1:552 N MCLEAN BLVD
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123
Practice Address - Country:US
Practice Address - Phone:847-931-9744
Practice Address - Fax:847-931-7726
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0226321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1003729Medicaid