=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790990422
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STEVEN W SEIBERT DMD, LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2007
-----------------------------------------------------
Last Update Date | 10/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3002 CROSSING CT
-----------------------------------------------------
City | CHAMPAIGN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61822-6135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-398-4867
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1804 BENTBROOK DR
-----------------------------------------------------
City | CHAMPAIGN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61822-9218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-352-2711
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. STEVEN W SEIBERT
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 217-398-4867
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 021001261
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------