Provider Demographics
NPI:1255401204
Name:SPENCER, RICHARD L (DDS)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:L
Last Name:SPENCER
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 1:2101 OSBORNE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558-9137
Mailing Address - Country:US
Mailing Address - Phone:912-882-6072
Mailing Address - Fax:912-882-6610
Practice Address - Street 1:2101 OSBORNE RD
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-9137
Practice Address - Country:US
Practice Address - Phone:912-882-6072
Practice Address - Fax:912-882-6610
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA94751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA581455186Medicaid