Provider Demographics
NPI:1417395138
Name:SPENCERVILLE DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:SPENCERVILLE DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIK
Authorized Official - Middle Name:J
Authorized Official - Last Name:RISOLVATO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:419-228-4036
Mailing Address - Street 1:201 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:SPENCERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45887-1290
Mailing Address - Country:US
Mailing Address - Phone:419-647-4972
Mailing Address - Fax:419-647-6795
Practice Address - Street 1:201 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:SPENCERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45887-1290
Practice Address - Country:US
Practice Address - Phone:419-647-4972
Practice Address - Fax:419-647-6795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-05
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty