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1405 Lilac Lane Drive North Suite 150 K Golden Valley MN 55422-4536 | |
| (763) 762-6549 | |
| (763) 762-6573 |
| Full Name | |
|---|---|
| Speciality | Dentist |
| Location | 1405 Lilac Lane Drive North, Golden Valley, Minnesota |
| Authorized Official Name and Position | Mariam Tahir Siddiqui (DR) |
| Authorized Official Contact | 6127350950 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
18500 County Road 6 Plymouth MN 55447-2531 Ph: (612) 735-0950 | 1405 Lilac Lane Drive North Suite 150 K Golden Valley MN 55422-4536 Ph: (763) 762-6549 |
| NPI Number | 1306513023 |
|---|---|
| Provider Enumeration Date | 08/30/2021 |
| Last Update Date | 06/09/2022 |
| Medicare PECOS PAC ID | 3779984604 |
|---|---|
| Medicare Enrollment ID | O20240925002496 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1306513023 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223S0112X | Dentist - Oral And Maxillofacial Surgery | (* (Not Available)) | Secondary |
| 1223X2210X | Dentist - Orofacial Pain | (* (Not Available)) | Primary |
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