Provider Demographics
NPI:1518076793
Name:SPORE, RAYMOND WENDEL SR (DDS)
Entity Type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:WENDEL
Last Name:SPORE
Suffix:SR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:RAYMOND
Other - Middle Name:W
Other - Last Name:SPORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS A DENTAL CORPORA
Mailing Address - Street 1:635 ANDERSON RD
Mailing Address - Street 2:STE #14
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616
Mailing Address - Country:US
Mailing Address - Phone:530-756-0953
Mailing Address - Fax:530-756-3588
Practice Address - Street 1:635 ANDERSON RD
Practice Address - Street 2:STE #14
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616
Practice Address - Country:US
Practice Address - Phone:530-756-0953
Practice Address - Fax:530-756-0953
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA180201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice