Provider Demographics
NPI:1326708975
Name:SPELLER, ANDRE L
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:L
Last Name:SPELLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 BIGELOW ST
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13904-1601
Mailing Address - Country:US
Mailing Address - Phone:601-336-2669
Mailing Address - Fax:
Practice Address - Street 1:19 BIGELOW ST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13904-1601
Practice Address - Country:US
Practice Address - Phone:601-336-2669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-22
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY371369475122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist