MEDICARE: TYLER ROSS SIEGFORD DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	8271966	ID

General Provider Information

NPI Number	:	1750275491
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYLER ROSS SIEGFORD DDS

Provider Business Mailing Address
First Line	:	PO BOX 1389
Second Line	:
City	:	SPIRIT LAKE
State	:	ID
Zip	:	83869-1389
Country	:	US
Telephone Number	:	208-623-6400
Fax Number	:	208-623-6464

Provider Business Practice Location Address
First Line	:	6070 W JACKSON ST
Second Line	:
City	:	SPIRIT LAKE
State	:	ID
Zip	:	83869-7742
Country	:	US
Telephone Number	:	208-623-6400
Fax Number	:	208-623-6464

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/06/2025
Last Update Date	:	06/06/2025

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