Provider Demographics
NPI:1952331241
Name:SPRUILL, GARY JAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:JAN
Last Name:SPRUILL
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 1:4745 BOARDWALK DR
Mailing Address - Street 2:BUILDING C , SUITE 2
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-3768
Mailing Address - Country:US
Mailing Address - Phone:970-229-9000
Mailing Address - Fax:907-204-1705
Practice Address - Street 1:4745 BOARDWALK DR
Practice Address - Street 2:BUILDING C, SUITE 2
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-3769
Practice Address - Country:US
Practice Address - Phone:970-229-9000
Practice Address - Fax:970-204-1705
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice