MEDICARE: MRS. PHUONG QUYNH NGOC SPICER D.M.D.

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	1223G0001X	General Practice Dentistry	DN015406	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DN015406	OTHER	GA	GEORGIA DENTAL LICENSE

General Provider Information

NPI Number	:	1790213700
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. PHUONG QUYNH NGOC SPICER D.M.D.

Provider Business Mailing Address
First Line	:	PO BOX 850
Second Line	:
City	:	HARLEM
State	:	GA
Zip	:	30814-0850
Country	:	US
Telephone Number	:	706-449-8352
Fax Number	:	706-449-8005

Provider Business Practice Location Address
First Line	:	150-160 NORTH LOUISVILLE STREET
Second Line	:
City	:	HARLEM
State	:	GA
Zip	:	30814-5084
Country	:	US
Telephone Number	:	706-449-8352
Fax Number	:	706-449-8005

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

Provider Enumeration Date	:	06/03/2017
Last Update Date	:	02/06/2023

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