Provider Demographics
NPI:1225218357
Name:BURTON, SPENCER JERALD (DDS)
Entity Type:Individual
Prefix:DR
First Name:SPENCER
Middle Name:JERALD
Last Name:BURTON
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 1:4920 SOUTH 30TH STREET
Mailing Address - Street 2:SUITE 103
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68107-1656
Mailing Address - Country:US
Mailing Address - Phone:402-932-7204
Mailing Address - Fax:402-952-1020
Practice Address - Street 1:4920 SOUTH 30TH STREET
Practice Address - Street 2:SUITE 103
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68107-1656
Practice Address - Country:US
Practice Address - Phone:402-932-7204
Practice Address - Fax:402-952-1020
Is Sole Proprietor?:No
Enumeration Date:2007-11-06
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7429122300000X
NE6935122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ483765Medicaid
NM78732280Medicaid