Provider Demographics
NPI:1376651166
Name:SIEGEL, ELLIOT B (DDS)
Entity Type:Individual
Prefix:DR
First Name:ELLIOT
Middle Name:B
Last Name:SIEGEL
Suffix:
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 1:930 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-2303
Mailing Address - Country:US
Mailing Address - Phone:516-541-2400
Mailing Address - Fax:516-541-9102
Practice Address - Street 1:930 N BROADWAY
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-2303
Practice Address - Country:US
Practice Address - Phone:516-541-2400
Practice Address - Fax:516-541-9102
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0319371223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYD6C311Medicare UPIN