Provider Demographics
NPI:1639563406
Name:SIEGFRIED,LLC
Entity Type:Organization
Organization Name:SIEGFRIED,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:DR
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:ERIN
Authorized Official - Last Name:SIEGFRIED
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:501-628-5555
Mailing Address - Street 1:12 MARLOU DR
Mailing Address - Street 2:
Mailing Address - City:CABOT
Mailing Address - State:AR
Mailing Address - Zip Code:72023-3693
Mailing Address - Country:US
Mailing Address - Phone:501-628-5555
Mailing Address - Fax:501-628-5556
Practice Address - Street 1:12 MARLOU DR
Practice Address - Street 2:
Practice Address - City:CABOT
Practice Address - State:AR
Practice Address - Zip Code:72023-3693
Practice Address - Country:US
Practice Address - Phone:501-628-5555
Practice Address - Fax:501-628-5556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-19
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR38381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR197469608Medicaid