Provider Demographics
NPI:1790213700
Name:SPICER, PHUONG QUYNH NGOC (DMD)
Entity Type:Individual
Prefix:MRS
First Name:PHUONG QUYNH
Middle Name:NGOC
Last Name:SPICER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:MS
Other - First Name:PHUONG QUYNH
Other - Middle Name:NGOC
Other - Last Name:LE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 850
Mailing Address - Street 2:
Mailing Address - City:HARLEM
Mailing Address - State:GA
Mailing Address - Zip Code:30814-0850
Mailing Address - Country:US
Mailing Address - Phone:706-449-8352
Mailing Address - Fax:706-449-8005
Practice Address - Street 1:150-160 NORTH LOUISVILLE STREET
Practice Address - Street 2:
Practice Address - City:HARLEM
Practice Address - State:GA
Practice Address - Zip Code:30814-5084
Practice Address - Country:US
Practice Address - Phone:706-449-8352
Practice Address - Fax:706-449-8005
Is Sole Proprietor?:No
Enumeration Date:2017-06-03
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0154061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GADN015406OtherGEORGIA DENTAL LICENSE