Provider Demographics
NPI:1740455716
Name:GW SPENCER, DDS, PC
Entity type:Organization
Organization Name:GW SPENCER, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:SPENCER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:660-826-3571
Mailing Address - Street 1:1716 W 11TH ST
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-5221
Mailing Address - Country:US
Mailing Address - Phone:660-826-3571
Mailing Address - Fax:660-826-3051
Practice Address - Street 1:1716 W 11TH ST
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-5221
Practice Address - Country:US
Practice Address - Phone:660-826-3571
Practice Address - Fax:660-826-3051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO11661261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO11661OtherSTATE LICENSE NUMBER