Healthcare Provider Details

I. General information

NPI: 1194385161
Provider Name (Legal Business Name): JORDAN R SIEGEL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2019
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 PERSHING DR STE 102
SILVER SPRING MD
20910-4436
US

IV. Provider business mailing address

8225 OSAGE LN
BETHESDA MD
20817-4405
US

V. Phone/Fax

Practice location:
  • Phone: 301-562-9455
  • Fax:
Mailing address:
  • Phone: 301-787-2156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDEN2000507
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDR-3119
License Number StateHI
# 3
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number18525
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: