Provider Demographics
NPI:1760892160
Name:SPENCER, EVANGELYN ALETHEIA (DMD)
Entity Type:Individual
Prefix:
First Name:EVANGELYN
Middle Name:ALETHEIA
Last Name:SPENCER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1303 DR MARTIN L KING JR AVE
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36603-5341
Mailing Address - Country:US
Mailing Address - Phone:251-432-4117
Mailing Address - Fax:
Practice Address - Street 1:1115 AZALEA PL
Practice Address - Street 2:
Practice Address - City:BREWTON
Practice Address - State:AL
Practice Address - Zip Code:36426-1318
Practice Address - Country:US
Practice Address - Phone:251-867-8020
Practice Address - Fax:251-867-8079
Is Sole Proprietor?:No
Enumeration Date:2014-05-07
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALD00061781223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL173506Medicaid