Provider Demographics
NPI:1740225036
Name:SIDOR, ANTHONY JOHN (DDS)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:JOHN
Last Name:SIDOR
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 S PLUMOSA ST
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32952-3525
Mailing Address - Country:US
Mailing Address - Phone:321-453-1890
Mailing Address - Fax:321-453-1521
Practice Address - Street 1:225 S PLUMOSA ST
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-3525
Practice Address - Country:US
Practice Address - Phone:321-453-1890
Practice Address - Fax:321-453-1521
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-19
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 131701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice