Provider Demographics
NPI:1497825152
Name:DEREK A SIEMON DDS LLC
Entity Type:Organization
Organization Name:DEREK A SIEMON DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:A
Authorized Official - Last Name:SIEMON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:410-263-7338
Mailing Address - Street 1:1833 G FOREST DR
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401
Mailing Address - Country:US
Mailing Address - Phone:410-263-7338
Mailing Address - Fax:410-263-7339
Practice Address - Street 1:1833 G FOREST DR
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401
Practice Address - Country:US
Practice Address - Phone:410-263-7338
Practice Address - Fax:410-263-7339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty