Provider Demographics
NPI:1851528962
Name:LAYNE, BRAD SPENCER (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:SPENCER
Last Name:LAYNE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4007
Mailing Address - Street 2:19606 SR 20 W
Mailing Address - City:BLOUNTSTOWN
Mailing Address - State:FL
Mailing Address - Zip Code:32424-4007
Mailing Address - Country:US
Mailing Address - Phone:850-674-5502
Mailing Address - Fax:850-674-9790
Practice Address - Street 1:19606 SR 20 W
Practice Address - Street 2:
Practice Address - City:BLOUNTSTOWN
Practice Address - State:FL
Practice Address - Zip Code:32424-3916
Practice Address - Country:US
Practice Address - Phone:850-674-5502
Practice Address - Fax:850-674-9790
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN187151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice