Provider Demographics
NPI:1306663414
Name:SAIDARA, GIDEON
Entity type:Individual
Prefix:
First Name:GIDEON
Middle Name:
Last Name:SAIDARA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 N LINDEN DR
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-3008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2030 W AVENUE J
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93536-5913
Practice Address - Country:US
Practice Address - Phone:661-949-6757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-21
Last Update Date:2024-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110766122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist