Provider Demographics
NPI:1528565256
Name:MULLENAUX, SPENCER WESLEY
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:WESLEY
Last Name:MULLENAUX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 EVE ORCHID DR
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:64034-7802
Mailing Address - Country:US
Mailing Address - Phone:928-651-5971
Mailing Address - Fax:
Practice Address - Street 1:12414 S US HIGHWAY 71
Practice Address - Street 2:
Practice Address - City:GRANDVIEW
Practice Address - State:MO
Practice Address - Zip Code:64030-1733
Practice Address - Country:US
Practice Address - Phone:816-307-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-10
Last Update Date:2023-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20200140681223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty