Provider Demographics
NPI:1164959169
Name:SIEW, MICHAEL MANCHANG JR (DDS, MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:MANCHANG
Last Name:SIEW
Suffix:JR
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10175 GATEWAY BLVD W STE 304
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-2203
Mailing Address - Country:US
Mailing Address - Phone:915-504-6880
Mailing Address - Fax:915-599-8579
Practice Address - Street 1:10175 GATEWAY BLVD W STE 304
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-2203
Practice Address - Country:US
Practice Address - Phone:915-504-6880
Practice Address - Fax:915-599-8579
Is Sole Proprietor?:No
Enumeration Date:2017-05-22
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXETN517390200000X
TX376661223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program