Healthcare Provider Details

I. General information

NPI: 1992144554
Provider Name (Legal Business Name): BEVERLY ZIDOR DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2013
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3509 BAKER ROAD SUITE 401
ACWORTH GA
30101-3010
US

IV. Provider business mailing address

3509 BAKER ROAD SUITE 401
ACWORTH GA
30101
US

V. Phone/Fax

Practice location:
  • Phone: 770-917-8943
  • Fax: 770-917-8943
Mailing address:
  • Phone: 770-917-8943
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number057730
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN015283
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: