Provider Demographics
NPI:1841251956
Name:SIEGEL, SCOTT A (DDS, MD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:A
Last Name:SIEGEL
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 BROADHOLLOW RD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-3671
Mailing Address - Country:US
Mailing Address - Phone:631-465-0300
Mailing Address - Fax:631-271-1593
Practice Address - Street 1:510 BROADHOLLOW RD
Practice Address - Street 2:SUITE 130
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-3671
Practice Address - Country:US
Practice Address - Phone:631-465-0300
Practice Address - Fax:631-271-1593
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0459231223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02145962Medicaid
NYD06501Medicare PIN
NY02145962Medicaid