Healthcare Provider Details

I. General information

NPI: 1285044529
Provider Name (Legal Business Name): KYLE JAMES SIEMEN, D.M.D., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2014
Last Update Date: 05/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 W CEDAR ST
POCATELLO ID
83201-5045
US

IV. Provider business mailing address

333 W CEDAR ST
POCATELLO ID
83201-5045
US

V. Phone/Fax

Practice location:
  • Phone: 208-233-6912
  • Fax: 208-233-6921
Mailing address:
  • Phone: 208-233-6912
  • Fax: 208-233-6921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD3403
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. KYLE JAMES SIEMEN
Title or Position: DENTIST/PRESIDENT
Credential: D.M.D
Phone: 208-233-6912