Provider Demographics
NPI:1891765822
Name:SPAIN, LON PATRICK (DDS)
Entity Type:Individual
Prefix:
First Name:LON
Middle Name:PATRICK
Last Name:SPAIN
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 1680
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25717-1680
Mailing Address - Country:US
Mailing Address - Phone:304-525-3334
Mailing Address - Fax:304-697-2086
Practice Address - Street 1:408 ALEXANDER STREET
Practice Address - Street 2:
Practice Address - City:CEDAR GROVE
Practice Address - State:WV
Practice Address - Zip Code:25039
Practice Address - Country:US
Practice Address - Phone:304-595-1770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3400122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100174300Medicaid
OH2036862Medicaid
WV7805006000Medicaid