Basic Information
Provider Information
NPI: 1942423900
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SIUDARA
FirstName: PETER
MiddleName: W.
NamePrefix: DR.
NameSuffix:  
Credential: D.D.S
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1578 CALLE PORTADA
Address2:  
City: CAMARILLO
State: CA
PostalCode: 930108420
CountryCode: US
TelephoneNumber: 8054842405
FaxNumber:  
Practice Location
Address1: 750 W GONZALES RD
Address2: SUITE 200
City: OXNARD
State: CA
PostalCode: 930369025
CountryCode: US
TelephoneNumber: 8059836010
FaxNumber:  
Other Information
ProviderEnumerationDate: 04/10/2007
LastUpdateDate: 07/08/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X23242CAY Dental ProvidersDentist 

No ID Information.


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