Provider Demographics
NPI:1992144554
Name:ZIDOR, BEVERLY (DDS)
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:ZIDOR
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3509 BAKER ROAD SUITE 401
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101
Mailing Address - Country:US
Mailing Address - Phone:770-917-8943
Mailing Address - Fax:
Practice Address - Street 1:3509 BAKER ROAD SUITE 401
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-3010
Practice Address - Country:US
Practice Address - Phone:770-917-8943
Practice Address - Fax:770-917-8943
Is Sole Proprietor?:No
Enumeration Date:2013-06-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0577301223G0001X
GADN0152831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice