Provider Demographics
NPI:1477150316
Name:BLACKHAM, SPENCER SONNTAG (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:SPENCER
Middle Name:SONNTAG
Last Name:BLACKHAM
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3097 E HIGH DANISH RD
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84093-5510
Mailing Address - Country:US
Mailing Address - Phone:847-907-1989
Mailing Address - Fax:
Practice Address - Street 1:4585 SILVER SPRINGS DR
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-5913
Practice Address - Country:US
Practice Address - Phone:435-649-0099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-05
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7894995-99211223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health