Active NPI
Tieg Bryant Selberg, DDS
- Pediatric Dentistry
- Glen Carbon, IL
National Provider Identifier
1831489954
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pediatric Dentistry
- License
- 021.002920
- Practice address
- 116 Magnolia Dr
Glen Carbon, IL 62034-1595 - Phone
- (618) 288-5437
- NPI assigned
- Apr 11, 2011
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatric Dentistry | 1223P0221X | 021.002920 | IL | Primary |
Addresses
Primary practice location
116 Magnolia Dr
Glen Carbon, IL 62034-1595
Mailing address
5 Abbey Rd
Glen Carbon, IL 62034-2928
Phone (612) 203-1034
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 021.002920 | IL | MD | Pediatric Dentist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Jenkins Pediatric Dentistry | Pediatric Dentistry | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Pediatric Dentistry
- Shawnee, KS
- NPI 1053922385
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1302480000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1639353600000",
"number": "1831489954",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "5 ABBEY RD",
"city": "GLEN CARBON",
"state": "IL",
"postal_code": "620342928",
"telephone_number": "612-203-1034"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "116 MAGNOLIA DR",
"city": "GLEN CARBON",
"state": "IL",
"postal_code": "620341595",
"telephone_number": "618-288-5437"
}
],
"practiceLocations": [],
"basic": {
"last_name": "SELBERG",
"first_name": "TIEG",
"middle_name": "BRYANT",
"credential": "DDS",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2011-04-11",
"last_updated": "2021-12-13",
"certification_date": "2021-12-13",
"status": "A"
},
"taxonomies": [
{
"code": "1223P0221X",
"taxonomy_group": "",
"desc": "Dentist, Pediatric Dentistry",
"state": "IL",
"license": "021.002920",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Glen Carbon, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 13, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.