Provider Demographics
NPI:1831489954
Name:SELBERG, TIEG BRYANT (DDS)
Entity Type:Individual
Prefix:
First Name:TIEG
Middle Name:BRYANT
Last Name:SELBERG
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 1:5 ABBEY RD
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-2928
Mailing Address - Country:US
Mailing Address - Phone:612-203-1034
Mailing Address - Fax:
Practice Address - Street 1:116 MAGNOLIA DR
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-1595
Practice Address - Country:US
Practice Address - Phone:618-288-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-11
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021.0029201223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry