Provider Demographics
NPI:1932727773
Name:CHIPPEWA CREEK DENTAL-DRS. SIEFKER AND JACKO DDS, LLC
Entity Type:Organization
Organization Name:CHIPPEWA CREEK DENTAL-DRS. SIEFKER AND JACKO DDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:SIEFKER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:330-769-2918
Mailing Address - Street 1:10 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44273-8851
Mailing Address - Country:US
Mailing Address - Phone:330-769-2918
Mailing Address - Fax:330-769-2888
Practice Address - Street 1:10 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SEVILLE
Practice Address - State:OH
Practice Address - Zip Code:44273-8851
Practice Address - Country:US
Practice Address - Phone:330-769-2918
Practice Address - Fax:330-769-2888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-08
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental