Provider Demographics
NPI:1194385161
Name:SIEGEL, JORDAN R
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:R
Last Name:SIEGEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8225 OSAGE LN
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20817-4405
Mailing Address - Country:US
Mailing Address - Phone:301-787-2156
Mailing Address - Fax:
Practice Address - Street 1:804 PERSHING DR STE 102
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-4436
Practice Address - Country:US
Practice Address - Phone:301-562-9455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-20
Last Update Date:2025-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDEN20005071223E0200X
HIDR-31191223E0200X
MD185251223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics