Provider Demographics
NPI:1710435151
Name:JACK D SPENCER,DMD
Entity Type:Organization
Organization Name:JACK D SPENCER,DMD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:SPENCER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:412-835-2288
Mailing Address - Street 1:180 FORT COUCH RD
Mailing Address - Street 2:ST 415
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15241-1041
Mailing Address - Country:US
Mailing Address - Phone:412-835-2288
Mailing Address - Fax:
Practice Address - Street 1:180 FORT COUCH RD
Practice Address - Street 2:ST 415
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15241-1041
Practice Address - Country:US
Practice Address - Phone:412-835-2288
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS 021308-L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty