Provider Demographics
NPI:1710193693
Name:SIEGEL, MARK DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DAVID
Last Name:SIEGEL
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 1:16055 VENTURA BLVD
Mailing Address - Street 2:SUITE 1030
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2601
Mailing Address - Country:US
Mailing Address - Phone:818-789-3263
Mailing Address - Fax:818-789-3294
Practice Address - Street 1:16055 VENTURA BLVD
Practice Address - Street 2:SUITE 1030
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2601
Practice Address - Country:US
Practice Address - Phone:818-789-3263
Practice Address - Fax:818-789-3294
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29466122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist