Provider Demographics
NPI:1740437672
Name:SPORY, PHILIP JAMES (DDS)
Entity type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:JAMES
Last Name:SPORY
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 1:15521 REAL ESTATE AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:KING GEORGE
Mailing Address - State:VA
Mailing Address - Zip Code:22485-5327
Mailing Address - Country:US
Mailing Address - Phone:540-693-0631
Mailing Address - Fax:
Practice Address - Street 1:15521 REAL ESTATE AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:KING GEORGE
Practice Address - State:VA
Practice Address - Zip Code:22485-5327
Practice Address - Country:US
Practice Address - Phone:540-693-0631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-21
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401413422122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5057872Medicaid