Provider Demographics
NPI:1073249769
Name:JARED B SIEGEL DDS PC
Entity type:Organization
Organization Name:JARED B SIEGEL DDS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JARED
Authorized Official - Middle Name:BENJAMIN
Authorized Official - Last Name:SIEGEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:631-374-8567
Mailing Address - Street 1:3052 N LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-4286
Mailing Address - Country:US
Mailing Address - Phone:773-997-1979
Mailing Address - Fax:
Practice Address - Street 1:3052 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-4286
Practice Address - Country:US
Practice Address - Phone:773-997-1979
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-26
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1740818848Medicaid
IL1740818848OtherINSURANCE