Provider Demographics
NPI:1285654848
Name:SPENCER, JAMISON ROSS (DMD)
Entity Type:Individual
Prefix:DR
First Name:JAMISON
Middle Name:ROSS
Last Name:SPENCER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8119 USTICK RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-5754
Mailing Address - Country:US
Mailing Address - Phone:205-376-3600
Mailing Address - Fax:208-376-3616
Practice Address - Street 1:8119 USTICK RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-5754
Practice Address - Country:US
Practice Address - Phone:205-376-3600
Practice Address - Fax:208-376-3616
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD33191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1003969288Medicare NSC
IDU80194Medicare UPIN
ID1204329Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER