=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164247391
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIDGEPOINTE DENTAL STUDIO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2024
-----------------------------------------------------
Last Update Date | 11/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 230 BRIDGE ST
-----------------------------------------------------
City | METUCHEN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08840-2291
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-479-0195
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 125 LONGVIEW ST
-----------------------------------------------------
City | WEST ORANGE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07052-4857
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-747-7904
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. EDDA Y SIDOROVA
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 201-747-7904
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------