Provider Demographics
NPI:1760961817
Name:SPIKA DENTAL, INC.
Entity Type:Organization
Organization Name:SPIKA DENTAL, INC.
Other - Org Name:MCGOVERN AND BORIN DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADFORD
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:SPIKA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:253-651-0705
Mailing Address - Street 1:PO BOX 2185
Mailing Address - Street 2:
Mailing Address - City:MAMMOTH LAKES
Mailing Address - State:CA
Mailing Address - Zip Code:93546-2185
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:312 W LINE ST
Practice Address - Street 2:
Practice Address - City:BISHOP
Practice Address - State:CA
Practice Address - Zip Code:93514-3413
Practice Address - Country:US
Practice Address - Phone:253-651-0705
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-09
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102998261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1841345444OtherNPI
CA1578603627OtherNPI