Provider Demographics
NPI:1033745344
Name:SIEGEL, KATIE PARK (DDS)
Entity Type:Individual
Prefix:DR
First Name:KATIE
Middle Name:PARK
Last Name:SIEGEL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10623 CARDERA DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-4705
Mailing Address - Country:US
Mailing Address - Phone:443-883-6402
Mailing Address - Fax:
Practice Address - Street 1:11246 SULLIVAN ST
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-2140
Practice Address - Country:US
Practice Address - Phone:813-530-0111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-18
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLDN262031223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program