Provider Demographics
NPI:1891840930
Name:BUTT, SIDRA (DDS)
Entity Type:Individual
Prefix:
First Name:SIDRA
Middle Name:
Last Name:BUTT
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 1:14631 CHARTER WALK CT
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23114-4694
Mailing Address - Country:US
Mailing Address - Phone:804-874-1598
Mailing Address - Fax:
Practice Address - Street 1:14631 CHARTER WALK CT
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23114-4694
Practice Address - Country:US
Practice Address - Phone:804-874-1598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA55391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1855391Medicaid
LA1940801Medicaid