Provider Demographics
NPI:1295884393
Name:SIEMERS, GAYLE R (DDS)
Entity type:Individual
Prefix:MR
First Name:GAYLE
Middle Name:R
Last Name:SIEMERS
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:#2 6TH AVE E.
Mailing Address - Street 2:
Mailing Address - City:POLSON
Mailing Address - State:MT
Mailing Address - Zip Code:59860
Mailing Address - Country:US
Mailing Address - Phone:406-883-6269
Mailing Address - Fax:406-883-9203
Practice Address - Street 1:#2 6TH AVE EAST
Practice Address - Street 2:
Practice Address - City:POLSON
Practice Address - State:MT
Practice Address - Zip Code:59860
Practice Address - Country:US
Practice Address - Phone:406-883-6269
Practice Address - Fax:406-883-9203
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT16174OtherBLUE CROS BLUE SHIELD MT
MT11-1618Medicaid