Provider Demographics
NPI:1457733289
Name:SPICER, CHARLES (DMD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:SPICER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 PARKSIDE MAIN
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30642-4543
Mailing Address - Country:US
Mailing Address - Phone:706-453-1333
Mailing Address - Fax:
Practice Address - Street 1:1011 PARKSIDE MAIN
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:GA
Practice Address - Zip Code:30642-4543
Practice Address - Country:US
Practice Address - Phone:706-453-1333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-29
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN015012122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist