Provider Demographics
NPI:1407984958
Name:MICHAEL D. SPENCER, DDS, LLC
Entity Type:Organization
Organization Name:MICHAEL D. SPENCER, DDS, LLC
Other - Org Name:RIVERSIDE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:SPENCER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:904-355-5531
Mailing Address - Street 1:1061 RIVERSIDE AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-4152
Mailing Address - Country:US
Mailing Address - Phone:904-355-5531
Mailing Address - Fax:904-791-9239
Practice Address - Street 1:1061 RIVERSIDE AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4152
Practice Address - Country:US
Practice Address - Phone:904-355-5531
Practice Address - Fax:904-791-9239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL89851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty