Provider Demographics
NPI:1720259013
Name:GREGORY V. SIERMINSKI, D.D.S., P.C.
Entity Type:Organization
Organization Name:GREGORY V. SIERMINSKI, D.D.S., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:VALENTINE
Authorized Official - Last Name:SIERMINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-728-0100
Mailing Address - Street 1:P.O. BOX 388
Mailing Address - Street 2:
Mailing Address - City:WONDER LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60097
Mailing Address - Country:US
Mailing Address - Phone:815-728-0100
Mailing Address - Fax:815-728-0114
Practice Address - Street 1:7442 HANCOCK DRIVE
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60097
Practice Address - Country:US
Practice Address - Phone:815-728-0100
Practice Address - Fax:815-728-0114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-14
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL101265Medicaid
IL1003734Medicaid