Provider Demographics
NPI:1861825895
Name:SPIVAK, STEVEN ROBERT (DMD)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:ROBERT
Last Name:SPIVAK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5410 RHODES AVENUE
Mailing Address - Street 2:#102
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91607-2079
Mailing Address - Country:US
Mailing Address - Phone:818-687-3111
Mailing Address - Fax:
Practice Address - Street 1:13114 SHERMAN WAY
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91605-4645
Practice Address - Country:US
Practice Address - Phone:818-982-6162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-13
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA625281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice