Provider Demographics
NPI:1134896632
Name:RICKERS, SPENCER
Entity type:Individual
Prefix:
First Name:SPENCER
Middle Name:
Last Name:RICKERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4002 HIDDEN HILLS CIR
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-1559
Mailing Address - Country:US
Mailing Address - Phone:801-960-6513
Mailing Address - Fax:
Practice Address - Street 1:444 FOREST SQ
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-4463
Practice Address - Country:US
Practice Address - Phone:903-758-5551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-24
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX377861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX37786OtherTEXAS LICENSE NUMBER