Provider Demographics
NPI:1447212170
Name:SPISAK, VIRGINIA W V (DMD)
Entity Type:Individual
Prefix:DR
First Name:VIRGINIA
Middle Name:W
Last Name:SPISAK
Suffix:V
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:VIRGINIA
Other - Middle Name:KATHLEEN
Other - Last Name:WRIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:BLDG 4405 INNKEEPER ST
Mailing Address - Street 2:
Mailing Address - City:FORT RUCKER
Mailing Address - State:AL
Mailing Address - Zip Code:36362
Mailing Address - Country:US
Mailing Address - Phone:334-255-3393
Mailing Address - Fax:
Practice Address - Street 1:BLDG 4405 INN KEEPER ST
Practice Address - Street 2:
Practice Address - City:FORT RUCKER
Practice Address - State:AL
Practice Address - Zip Code:36362
Practice Address - Country:US
Practice Address - Phone:334-255-3393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 140831223G0001X
ALLNO 39101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice