Provider Demographics
NPI:1457484461
Name:SIEGRIST, JACK B JR (DDS)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:B
Last Name:SIEGRIST
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 1:2100 TREE TOP CT
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76049-8067
Mailing Address - Country:US
Mailing Address - Phone:972-556-2122
Mailing Address - Fax:972-556-2331
Practice Address - Street 1:5205 N O CONNOR BLVD
Practice Address - Street 2:#150
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75039-3707
Practice Address - Country:US
Practice Address - Phone:972-556-2122
Practice Address - Fax:972-556-2331
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX99501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice