Provider Demographics
NPI:1285044529
Name:KYLE JAMES SIEMEN, D.M.D., P.A.
Entity Type:Organization
Organization Name:KYLE JAMES SIEMEN, D.M.D., P.A.
Other - Org Name:SAGE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:SIEMEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-233-6912
Mailing Address - Street 1:333 W CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5045
Mailing Address - Country:US
Mailing Address - Phone:208-233-6912
Mailing Address - Fax:208-233-6921
Practice Address - Street 1:333 W CEDAR ST
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5045
Practice Address - Country:US
Practice Address - Phone:208-233-6912
Practice Address - Fax:208-233-6921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-07
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3403122300000X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty