Provider Demographics
NPI:1790785061
Name:SPACKMAN, GREGORY KEITH (DDS MBA)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:KEITH
Last Name:SPACKMAN
Suffix:
Gender:M
Credentials:DDS MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7703 FLOYD CURL DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3901
Mailing Address - Country:US
Mailing Address - Phone:210-567-3470
Mailing Address - Fax:210-567-2995
Practice Address - Street 1:7703 FLOYD CURL DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3901
Practice Address - Country:US
Practice Address - Phone:210-567-3477
Practice Address - Fax:210-567-3493
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX174541223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX126785803Medicaid
TX126780805OtherMEDICAL DENTAL
TX126785803Medicaid
T42802Medicare UPIN