=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083283659
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDDA YESENIA SIDOROVA DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2021
-----------------------------------------------------
Last Update Date | 04/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 230 BRIDGE ST
-----------------------------------------------------
City | METUCHEN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08840-2291
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-494-7877
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 230 BRIDGE ST
-----------------------------------------------------
City | METUCHEN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08840-2291
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-494-7877
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 26059
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------