Provider Demographics
NPI:1457499378
Name:SIEBERT, JEFFREY R (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:R
Last Name:SIEBERT
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 1:1422 W MAIN ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-3331
Mailing Address - Country:US
Mailing Address - Phone:972-436-0275
Mailing Address - Fax:972-219-3931
Practice Address - Street 1:1422 W MAIN ST
Practice Address - Street 2:SUITE 202
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-3331
Practice Address - Country:US
Practice Address - Phone:972-436-0275
Practice Address - Fax:972-219-3931
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX197291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX21667OtherSTATE DENTAL LICENSE #
TX9582OtherDENTAL HYGIENE LICENSE