Provider Demographics
NPI:1386716975
Name:SIDERMAN, JERRY (DDS)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:
Last Name:SIDERMAN
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 1:6601 RUGBY AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-4046
Mailing Address - Country:US
Mailing Address - Phone:323-585-1515
Mailing Address - Fax:323-585-2199
Practice Address - Street 1:6601 RUGBY AVE STE 400
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-4046
Practice Address - Country:US
Practice Address - Phone:323-585-1515
Practice Address - Fax:323-585-2199
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA417891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG91803OtherDENTI-CAL PROVIDER NUMBER