Provider Demographics
NPI:1598881625
Name:SPELL, RICHARD GLEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:GLEN
Last Name:SPELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17517 MILLION DOLLAR RD.
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70435
Mailing Address - Country:US
Mailing Address - Phone:985-892-7665
Mailing Address - Fax:
Practice Address - Street 1:79132 HWY 40
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70435
Practice Address - Country:US
Practice Address - Phone:985-893-3900
Practice Address - Fax:985-893-2910
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN41171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice