Healthcare Provider Details

I. General information

NPI: 1396949541
Provider Name (Legal Business Name): SIDERMAN, YAMPOLSKY DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 08/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6601 RUGBY AVE #400
HUNTINGTON PARK CA
90255-4040
US

IV. Provider business mailing address

6601 RUGBY AVE #400
HUNTINGTON PARK CA
90255-4040
US

V. Phone/Fax

Practice location:
  • Phone: 323-585-1515
  • Fax:
Mailing address:
  • Phone: 323-585-1515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. JERRY SIDERMAN
Title or Position: PRESIDENT
Credential: DDS
Phone: 323-585-1515