MEDICARE: SPENCER FAMILY DENTISTRY

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	122300000X	Dentist	6039	OK

General Provider Information

NPI Number	:	1730472101
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPENCER FAMILY DENTISTRY

Provider Business Mailing Address
First Line	:	9060 HARMONY DR STE D
Second Line	:
City	:	MIDWEST CITY
State	:	OK
Zip	:	73130-6253
Country	:	US
Telephone Number	:	405-732-1012
Fax Number	:	405-733-8296

Provider Business Practice Location Address
First Line	:	9060 HARMONY DR STE D
Second Line	:
City	:	MIDWEST CITY
State	:	OK
Zip	:	73130-6253
Country	:	US
Telephone Number	:	405-732-1012
Fax Number	:	405-733-8296

Authorized Official
Title or Position	:	PRESIDENT/ SECTARY
Name	:	DR. LAURAN RUTH SPENCER
Credential	:	D.D.S.
Telephone Number	:	405-732-1012

Provider Enumeration Date	:	05/18/2011
Last Update Date	:	05/18/2011

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