Provider Demographics
NPI:1659548154
Name:SIEGMUND, JOHN DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DAVID
Last Name:SIEGMUND
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 1:730 WHALERS WAY
Mailing Address - Street 2:#100
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-7585
Mailing Address - Country:US
Mailing Address - Phone:970-226-2920
Mailing Address - Fax:
Practice Address - Street 1:730 WHALERS WAY
Practice Address - Street 2:#100
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-7585
Practice Address - Country:US
Practice Address - Phone:970-226-2920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5562122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO5562OtherSTATE DENTAL LICENSE