Provider Demographics
NPI:1205030491
Name:SIVERSON, JONATHAN ISAK (DDS)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:ISAK
Last Name:SIVERSON
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 1:1291 NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-1632
Mailing Address - Country:US
Mailing Address - Phone:612-360-1713
Mailing Address - Fax:
Practice Address - Street 1:4700 WHITE BEAR PKWY
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3336
Practice Address - Country:US
Practice Address - Phone:651-762-7677
Practice Address - Fax:651-762-1861
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND124101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice