Provider Demographics
NPI:1376756346
Name:SPACKMAN, SUE S (DDS)
Entity Type:Individual
Prefix:DR
First Name:SUE
Middle Name:S
Last Name:SPACKMAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1920 HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-3120
Mailing Address - Country:US
Mailing Address - Phone:310-318-9502
Mailing Address - Fax:
Practice Address - Street 1:100 UCLA MEDICAL PLZ
Practice Address - Street 2:SUITE 350
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-0001
Practice Address - Country:US
Practice Address - Phone:310-794-5750
Practice Address - Fax:310-208-0786
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA321831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice