MEDICARE: SUSAN R SIEGEL D.D.S.

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	033986	NY

General Provider Information

NPI Number	:	1811210560
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN R SIEGEL D.D.S.

Provider Business Mailing Address
First Line	:	3515 HENRY HUDSON PKWY
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10463-1326
Country	:	US
Telephone Number	:	718-796-2500
Fax Number	:	718-548-7858

Provider Business Practice Location Address
First Line	:	3515 HENRY HUDSON PKWY
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10463-1326
Country	:	US
Telephone Number	:	718-796-2500
Fax Number	:	718-548-7858

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

Provider Enumeration Date	:	03/09/2010
Last Update Date	:	03/10/2010

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