Healthcare Provider Details

I. General information

NPI: 1790990422
Provider Name (Legal Business Name): STEVEN W SEIBERT DMD, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 10/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3002 CROSSING CT
CHAMPAIGN IL
61822-6135
US

IV. Provider business mailing address

1804 BENTBROOK DR
CHAMPAIGN IL
61822-9218
US

V. Phone/Fax

Practice location:
  • Phone: 217-398-4867
  • Fax:
Mailing address:
  • Phone: 217-352-2711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number021001261
License Number StateIL

VIII. Authorized Official

Name: DR. STEVEN W SEIBERT
Title or Position: PRESIDENT
Credential: DMD
Phone: 217-398-4867