Provider Demographics
NPI:1740309368
Name:SIDAWI, MARY (DMD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:SIDAWI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83 LLANFAIR CIR
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:PA
Mailing Address - Zip Code:19003-3342
Mailing Address - Country:US
Mailing Address - Phone:610-642-2550
Mailing Address - Fax:610-642-6566
Practice Address - Street 1:83 LLANFAIR CIR
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:PA
Practice Address - Zip Code:19003-3342
Practice Address - Country:US
Practice Address - Phone:610-642-2550
Practice Address - Fax:610-642-6566
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0354391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice