MEDICARE: DR. JILLIAN DETTLOFF SEGLEM DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	2901020632	MI
2	1223P0221X	Pediatric Dentistry	117	OK
3	1223P0221X	Pediatric Dentistry	34968	TX

General Provider Information

NPI Number	:	1801143581
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JILLIAN DETTLOFF SEGLEM DDS

Provider Business Mailing Address
First Line	:	DENTAC FORT SILL
Second Line	:	605 RANDOLPH RD.
City	:	FORT SILL
State	:	OK
Zip	:	73505
Country	:	US
Telephone Number	:	580-442-3146
Fax Number	:

Provider Business Practice Location Address
First Line	:	DENTAC FORT SILL
Second Line	:	605 RANDOLPH RD.
City	:	FORT SILL
State	:	OK
Zip	:	73505
Country	:	US
Telephone Number	:	580-442-3146
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/13/2012
Last Update Date	:	02/01/2021

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