Provider Demographics
NPI:1912072075
Name:SPIVAK, VADIM L (DDS)
Entity Type:Individual
Prefix:DR
First Name:VADIM
Middle Name:L
Last Name:SPIVAK
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 1:6251 EXECUTIVE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-3906
Mailing Address - Country:US
Mailing Address - Phone:240-242-4737
Mailing Address - Fax:
Practice Address - Street 1:6251 EXECUTIVE BLVD
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-3906
Practice Address - Country:US
Practice Address - Phone:240-242-4737
Practice Address - Fax:240-242-4750
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13921122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist