Provider Demographics
NPI:1235270349
Name:SIEFERT, TOD WALDEN JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:TOD
Middle Name:WALDEN
Last Name:SIEFERT
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2880 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43204-2645
Mailing Address - Country:US
Mailing Address - Phone:614-279-0674
Mailing Address - Fax:
Practice Address - Street 1:2880 W BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43204-2645
Practice Address - Country:US
Practice Address - Phone:614-279-0674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH164911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice