Provider Demographics
NPI:1801143581
Name:SEGLEM, JILLIAN DETTLOFF (DDS)
Entity type:Individual
Prefix:DR
First Name:JILLIAN
Middle Name:DETTLOFF
Last Name:SEGLEM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:JILLIAN
Other - Middle Name:NICOLE
Other - Last Name:DETTLOFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:DENTAC FORT SILL
Mailing Address - Street 2:605 RANDOLPH RD.
Mailing Address - City:FORT SILL
Mailing Address - State:OK
Mailing Address - Zip Code:73505
Mailing Address - Country:US
Mailing Address - Phone:580-442-3146
Mailing Address - Fax:
Practice Address - Street 1:DENTAC FORT SILL
Practice Address - Street 2:605 RANDOLPH RD.
Practice Address - City:FORT SILL
Practice Address - State:OK
Practice Address - Zip Code:73505
Practice Address - Country:US
Practice Address - Phone:580-442-3146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-13
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901020632122300000X
OK1171223P0221X
TX349681223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist