Provider Demographics
NPI:1831109099
Name:SIDOW, STEPHANIE JANE (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:JANE
Last Name:SIDOW
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 1:1430 JOHN WESLEY GILBERT DRIVE
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30912-0001
Mailing Address - Country:US
Mailing Address - Phone:706-721-4225
Mailing Address - Fax:706-723-0218
Practice Address - Street 1:1430 JOHN WESLEY GILBERT DRIVE
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-5660
Practice Address - Country:US
Practice Address - Phone:706-721-4225
Practice Address - Fax:706-723-0218
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI39871223E0200X
FLDN239011223E0200X
GADN0150681223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics