Provider Demographics
NPI:1790947265
Name:SPENCER, ERIC W
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:W
Last Name:SPENCER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4735 OGLETOWN STANTON RD
Mailing Address - Street 2:MEDICAL ARTS PAVILION 2, STE 1115
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-2072
Mailing Address - Country:US
Mailing Address - Phone:302-292-1600
Mailing Address - Fax:302-292-8629
Practice Address - Street 1:4735 OGLETOWN STANTON RD
Practice Address - Street 2:MEDICAL ARTS PAVILION 2, STE 1115
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2072
Practice Address - Country:US
Practice Address - Phone:302-292-1600
Practice Address - Fax:302-292-8629
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEG1-00013321223S0112X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE540323ZYM0Medicare PIN
DE540323ZAXJMedicare PIN