Provider Demographics
NPI:1477701951
Name:SPENCER CREEK DENTAL CARE, LLC
Entity Type:Organization
Organization Name:SPENCER CREEK DENTAL CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MONROE
Authorized Official - Middle Name:MITCHELL
Authorized Official - Last Name:GINSBURG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:636-928-0880
Mailing Address - Street 1:5600 MEXICO RD
Mailing Address - Street 2:SUITE #20
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-1660
Mailing Address - Country:US
Mailing Address - Phone:636-928-0880
Mailing Address - Fax:636-928-6866
Practice Address - Street 1:5600 MEXICO RD
Practice Address - Street 2:SUITE #20
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1660
Practice Address - Country:US
Practice Address - Phone:636-928-0880
Practice Address - Fax:636-928-6866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-08
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MODE0137821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty