Provider Demographics
NPI:1376567891
Name:SPELLER, JADA JOHNSON (DDS)
Entity type:Individual
Prefix:DR
First Name:JADA
Middle Name:JOHNSON
Last Name:SPELLER
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 1:1315 E 52ND ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-4049
Mailing Address - Country:US
Mailing Address - Phone:773-363-5654
Mailing Address - Fax:773-363-5654
Practice Address - Street 1:25882 ORCHARD LAKE RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-1292
Practice Address - Country:US
Practice Address - Phone:888-833-8441
Practice Address - Fax:888-330-4331
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-023542122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL103180Medicaid