Provider Demographics
NPI:1356654172
Name:SPENCER C WIRIG, DMD, INC
Entity Type:Organization
Organization Name:SPENCER C WIRIG, DMD, INC
Other - Org Name:LAKEVIEW DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SPENCER
Authorized Official - Middle Name:C
Authorized Official - Last Name:WIRIG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-664-0884
Mailing Address - Street 1:801 W MILWAUKEE DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2236
Mailing Address - Country:US
Mailing Address - Phone:208-664-0884
Mailing Address - Fax:208-664-3304
Practice Address - Street 1:801 W MILWAUKEE DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2236
Practice Address - Country:US
Practice Address - Phone:208-664-0884
Practice Address - Fax:208-664-3304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-21
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD4020122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty