Provider Demographics
NPI:1417351289
Name:SIFFRARD FAMILY DENTISTRY, PLLC
Entity Type:Organization
Organization Name:SIFFRARD FAMILY DENTISTRY, PLLC
Other - Org Name:DREAMTEAM FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JANITA
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:SIFFRARD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:662-895-3000
Mailing Address - Street 1:6760 GOODMAN RD
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654
Mailing Address - Country:US
Mailing Address - Phone:662-895-3000
Mailing Address - Fax:662-895-3021
Practice Address - Street 1:6760 GOODMAN RD
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654
Practice Address - Country:US
Practice Address - Phone:662-895-3000
Practice Address - Fax:662-895-3021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-22
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS348908122300000X
MS3686-13122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09523504Medicaid
MS09822823Medicaid