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General NPI Number Information
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NPI Number | 1134441132
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Entity Type | Organization
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Legal Business Name | KENT M. SIEBOLDT, OD, PA
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Dates
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Enumeration Date | 02/18/2010
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Last Update Date | 02/18/2010
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Provider Practice Location Address
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Address Line | 324 E BLOOMINGDALE AVE
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City | BRANDON
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State | FL
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Zip | 33511-8155
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Country | US
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Telephone | 813-685-2646
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Fax | 813-681-6821
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Provider Business Mailing Address
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Address Line | 324 E BLOOMINGDALE AVE
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City | BRANDON
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State | FL
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Zip | 33511-8155
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Country | US
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Telephone | 813-685-2646
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Fax | 813-681-6821
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Authorized Official
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Title or Position | PRESIDENT
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Name | KENT M. SIEBOLDT
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Credential | OD
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Telephone | 813-685-2646
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2120
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License Number State | FL
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