Healthcare Provider Details

I. General information

NPI: 1184288276
Provider Name (Legal Business Name): MATTHEW SIEVERDING
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2019
Last Update Date: 04/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 EDGEWOOD RD SW STE 1
CEDAR RAPIDS IA
52404-4734
US

IV. Provider business mailing address

2215 EDGEWOOD RD SW STE 1
CEDAR RAPIDS IA
52404-4734
US

V. Phone/Fax

Practice location:
  • Phone: 319-409-5950
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDDS-09630
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: