Provider Demographics
NPI:1659653772
Name:SIEBENECK, SAMANTHA (DDS)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:
Last Name:SIEBENECK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1180 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43205-1902
Mailing Address - Country:US
Mailing Address - Phone:614-645-5541
Mailing Address - Fax:
Practice Address - Street 1:1180 E MAIN ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-1902
Practice Address - Country:US
Practice Address - Phone:614-645-5541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-14
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-023572122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist