Provider Demographics
NPI:1336843002
Name:SPANGLE, BROCK (DDS)
Entity Type:Individual
Prefix:
First Name:BROCK
Middle Name:
Last Name:SPANGLE
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 1:3505 N STATE ROAD 15 STE A
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46582-5504
Mailing Address - Country:US
Mailing Address - Phone:574-269-1199
Mailing Address - Fax:574-269-4452
Practice Address - Street 1:3505 N STATE ROAD 15 STE A
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46582-5504
Practice Address - Country:US
Practice Address - Phone:574-269-1199
Practice Address - Fax:574-269-4452
Is Sole Proprietor?:No
Enumeration Date:2023-03-28
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12014127A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice