Provider Demographics
NPI:1831753177
Name:SIDO, EDIRIN ELAINE (DMD)
Entity type:Individual
Prefix:DR
First Name:EDIRIN
Middle Name:ELAINE
Last Name:SIDO
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:PO BOX 2357
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:CA
Mailing Address - Zip Code:94568-0235
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4135 BLACKHAWK PLAZA CIR STE 260
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94506-4655
Practice Address - Country:US
Practice Address - Phone:925-837-7745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-23
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD111211223G0001X, 1223P0221X
NMDB-2023-00581223P0221X
CA1069591223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice