Provider Demographics
NPI:1902983067
Name:D SIM SICELOFF DDS PA
Entity Type:Organization
Organization Name:D SIM SICELOFF DDS PA
Other - Org Name:D SIM SICELOFF III DDS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:SIMEON
Authorized Official - Last Name:SICELOFF
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:336-249-6524
Mailing Address - Street 1:PO BOX 848
Mailing Address - Street 2:19 EAST SECOND AVENUE
Mailing Address - City:LEXINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27292
Mailing Address - Country:US
Mailing Address - Phone:336-249-6524
Mailing Address - Fax:336-248-1060
Practice Address - Street 1:19 EAST SECOND AVENUE
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:NC
Practice Address - Zip Code:27292
Practice Address - Country:US
Practice Address - Phone:336-249-6524
Practice Address - Fax:336-248-1060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8997790Medicaid