Basic Information
| Provider Information | |||||||||
| NPI: | 1689682635 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIDANA | ||||||||
| FirstName: | HANITA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 S WELLS RD | ||||||||
| Address2: | #200 | ||||||||
| City: | VENTURA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930041377 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056591740 | ||||||||
| FaxNumber: | 8056593217 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 S WELLS RD | ||||||||
| Address2: | #200 | ||||||||
| City: | VENTURA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930041377 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056591740 | ||||||||
| FaxNumber: | 8056593217 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 07/10/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 53336 | CA | Y | Dental Providers | Dentist | General Practice | 1223G0001X | 13524 | MD | N | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | G93684-01 | 05 | CA | MEDICAID |