Provider Demographics
NPI:1730667601
Name:J. SIDERMAN DDS A PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:J. SIDERMAN DDS A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:SIDERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:562-246-9989
Mailing Address - Street 1:9202 ALONDRA BLVD
Mailing Address - Street 2:
Mailing Address - City:BELLFLOWER
Mailing Address - State:CA
Mailing Address - Zip Code:90706-4210
Mailing Address - Country:US
Mailing Address - Phone:562-246-9989
Mailing Address - Fax:562-263-9667
Practice Address - Street 1:9202 ALONDRA BLVD
Practice Address - Street 2:
Practice Address - City:BELLFLOWER
Practice Address - State:CA
Practice Address - Zip Code:90706-4210
Practice Address - Country:US
Practice Address - Phone:562-246-9989
Practice Address - Fax:562-263-9667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41789261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherDENTAL