MEDICARE: DR. SPENCER E. MAUSETH D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	DDS61986	CA

General Provider Information

NPI Number	:	1619187390
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SPENCER E. MAUSETH D.D.S.

Provider Business Mailing Address
First Line	:	859 S YELLOWSTONE HWY
Second Line	:	SUITE #1202
City	:	REXBURG
State	:	ID
Zip	:	83440-5293
Country	:	US
Telephone Number	:	208-552-5439
Fax Number	:	208-552-5440

Provider Business Practice Location Address
First Line	:	859 S YELLOWSTONE HWY
Second Line	:	SUITE #1202
City	:	REXBURG
State	:	ID
Zip	:	83440-5293
Country	:	US
Telephone Number	:	208-552-5439
Fax Number	:	208-552-5440

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	08/07/2019

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