Provider Demographics
NPI:1649362906
Name:SIEBRASSE, EDWIN CHRISTIAN (DDS)
Entity type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:CHRISTIAN
Last Name:SIEBRASSE
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 1:303 SW 7TH ST.
Mailing Address - Street 2:SUITE D
Mailing Address - City:STUART
Mailing Address - State:IA
Mailing Address - Zip Code:50250
Mailing Address - Country:US
Mailing Address - Phone:515-523-2521
Mailing Address - Fax:515-523-2162
Practice Address - Street 1:303 SW 7TH ST.
Practice Address - Street 2:SUITE D
Practice Address - City:STUART
Practice Address - State:IA
Practice Address - Zip Code:50250
Practice Address - Country:US
Practice Address - Phone:515-523-2521
Practice Address - Fax:515-523-2162
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA066441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0220905Medicaid