Provider Demographics
NPI:1033565205
Name:WIDDIS, SHERI (CDA, RDA)
Entity Type:Individual
Prefix:
First Name:SHERI
Middle Name:
Last Name:WIDDIS
Suffix:
Gender:F
Credentials:CDA, RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4711 MOORPARK AVE
Mailing Address - Street 2:27
Mailing Address - City:MOORPARK
Mailing Address - State:CA
Mailing Address - Zip Code:93021-4125
Mailing Address - Country:US
Mailing Address - Phone:609-846-6460
Mailing Address - Fax:
Practice Address - Street 1:4711 MOORPARK AVE
Practice Address - Street 2:27
Practice Address - City:MOORPARK
Practice Address - State:CA
Practice Address - Zip Code:93021-4125
Practice Address - Country:US
Practice Address - Phone:609-846-6460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-06
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42174126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant