MEDICARE: DR. STEVEN LUBY SIDOFF SR. DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	14992	TX

General Provider Information

NPI Number	:	1922073279
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEVEN LUBY SIDOFF SR. DDS

Provider Business Mailing Address
First Line	:	15811 PONDEROSA PASS
Second Line	:
City	:	HELOTES
State	:	TX
Zip	:	78023-3685
Country	:	US
Telephone Number	:	847-274-2774
Fax Number	:

Provider Business Practice Location Address
First Line	:	3145 GARDEN AVE
Second Line	:	1278
City	:	FORT SAM HOUSTON
State	:	TX
Zip	:	78234-7718
Country	:	US
Telephone Number	:	210-808-3735
Fax Number	:	210-808-3802

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/21/2006
Last Update Date	:	04/25/2014

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