Healthcare Provider Details

I. General information

NPI: 1477991065
Provider Name (Legal Business Name): SPENCER PRESTON GORDY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2013
Last Update Date: 06/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 CHESTNUT ST
CONWAY AR
72032-5402
US

IV. Provider business mailing address

1623 CENTER ST
LITTLE ROCK AR
72206-1415
US

V. Phone/Fax

Practice location:
  • Phone: 501-329-8754
  • Fax:
Mailing address:
  • Phone: 501-733-1677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3926
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: