Provider Demographics
NPI:1972694958
Name:SPENCER, SUZANNE SEGEBARTH (DMD)
Entity Type:Individual
Prefix:DR
First Name:SUZANNE
Middle Name:SEGEBARTH
Last Name:SPENCER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 NORTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431
Mailing Address - Country:US
Mailing Address - Phone:270-825-2686
Mailing Address - Fax:270-821-7306
Practice Address - Street 1:2100 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-9007
Practice Address - Country:US
Practice Address - Phone:270-825-2686
Practice Address - Fax:270-821-7306
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY82951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60003654Medicaid