Provider Demographics
NPI:1952311078
Name:SIEMEN, KYLE JAMES (DMD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:JAMES
Last Name:SIEMEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4653 MOUNTAIN PARK RD
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83202-1702
Mailing Address - Country:US
Mailing Address - Phone:208-478-8705
Mailing Address - Fax:
Practice Address - Street 1:333 W CEDAR ST
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5045
Practice Address - Country:US
Practice Address - Phone:208-233-6912
Practice Address - Fax:208-233-6921
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-34031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice