Provider Demographics
NPI:1316982937
Name:SIECK, LONNIE V (DDS)
Entity type:Individual
Prefix:DR
First Name:LONNIE
Middle Name:V
Last Name:SIECK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 MARK DR
Mailing Address - Street 2:
Mailing Address - City:EDENTON
Mailing Address - State:NC
Mailing Address - Zip Code:27932-1704
Mailing Address - Country:US
Mailing Address - Phone:252-482-5105
Mailing Address - Fax:252-482-5587
Practice Address - Street 1:103 MARK DR
Practice Address - Street 2:
Practice Address - City:EDENTON
Practice Address - State:NC
Practice Address - Zip Code:27932-1704
Practice Address - Country:US
Practice Address - Phone:252-482-5105
Practice Address - Fax:252-482-5587
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC38301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3830OtherDENTAL LICENSE
NC89977912OtherNC BLUE CROSS PROVIDER NO
NC89977912OtherNC BLUE CROSS PROVIDER NO