Provider Demographics
NPI:1336765254
Name:SPACEK, CAITLIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:CAITLIN
Middle Name:
Last Name:SPACEK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 45TH ST S STE 108
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-3247
Mailing Address - Country:US
Mailing Address - Phone:701-526-4652
Mailing Address - Fax:
Practice Address - Street 1:2704 12TH ST S
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-4621
Practice Address - Country:US
Practice Address - Phone:218-233-0570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-17
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND14526122300000X
ND24041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist