MEDICARE: CHIPPEWA CREEK DENTAL-DRS. SIEFKER AND JACKO DDS, LLC

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1932727773
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHIPPEWA CREEK DENTAL-DRS. SIEFKER AND JACKO DDS, LLC

Provider Business Mailing Address
First Line	:	10 W MAIN ST
Second Line	:
City	:	SEVILLE
State	:	OH
Zip	:	44273-8851
Country	:	US
Telephone Number	:	330-769-2918
Fax Number	:	330-769-2888

Provider Business Practice Location Address
First Line	:	10 W MAIN ST
Second Line	:
City	:	SEVILLE
State	:	OH
Zip	:	44273-8851
Country	:	US
Telephone Number	:	330-769-2918
Fax Number	:	330-769-2888

Authorized Official
Title or Position	:	CEO
Name	:	DR. JONATHAN R SIEFKER
Credential	:	DDS
Telephone Number	:	330-769-2918

Provider Enumeration Date	:	07/08/2020
Last Update Date	:	07/08/2020

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