Provider Demographics
NPI:1194218099
Name:GROSS, SPENCER LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:SPENCER
Middle Name:LEE
Last Name:GROSS
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 1:47217 273RD ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:SD
Mailing Address - Zip Code:57032-8124
Mailing Address - Country:US
Mailing Address - Phone:605-354-3353
Mailing Address - Fax:
Practice Address - Street 1:4501 E 41ST ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57110-7200
Practice Address - Country:US
Practice Address - Phone:605-339-1369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-14
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDD1199122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist