Healthcare Provider Details

I. General information

NPI: 1205938826
Provider Name (Legal Business Name): JOHN CLINTON SIEWEKE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2006
Last Update Date: 05/16/2022
Certification Date: 04/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PIKE PLAZA 417 PLAZA DR.
ZEBULON GA
30295-3029
US

IV. Provider business mailing address

636 E COLLEGE ST
GRIFFIN GA
30224-4311
US

V. Phone/Fax

Practice location:
  • Phone: 770-227-9693
  • Fax:
Mailing address:
  • Phone: 770-639-2248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number9102
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: