Basic Information
| Provider Information | |||||||||
| NPI: | 1487043618 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALSADIQ | ||||||||
| FirstName: | SALAM | ||||||||
| MiddleName: | |||||||||
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| Credential: | BDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 DIMOCK ST | ||||||||
| Address2: | |||||||||
| City: | ROXBURY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021191029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174428800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 29777 TELEGRAPH RD STE 3000 | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480347634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3136477398 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2015 | ||||||||
| LastUpdateDate: | 09/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0221X | DL13738 | MA | N | Dental Providers | Dentist | Pediatric Dentistry | 1223P0221X | DL13958 | MA | N | Dental Providers | Dentist | Pediatric Dentistry | 1223P0221X | 2901600775 | MI | Y | Dental Providers | Dentist | Pediatric Dentistry |
ID Information
| ID | Type | State | Issuer | Description | S91870275 | 01 | MA | MA DRIVER'S LICENSE | OTHER |