Provider Demographics
NPI:1902056807
Name:SIDHU, INDRA (DDS)
Entity Type:Individual
Prefix:
First Name:INDRA
Middle Name:
Last Name:SIDHU
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:595 MAIN ST
Mailing Address - Street 2:SUITE 237
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-4352
Mailing Address - Country:US
Mailing Address - Phone:301-498-0002
Mailing Address - Fax:
Practice Address - Street 1:595 MAIN ST
Practice Address - Street 2:SUITE 237
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-4352
Practice Address - Country:US
Practice Address - Phone:301-498-0002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-26
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD112951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD11295OtherSTATE LICENCE