Healthcare Provider Details

I. General information

NPI: 1386100105
Provider Name (Legal Business Name): SPENCER MECHAM DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2019
Last Update Date: 02/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10750 W MCDOWELL RD STE F610
AVONDALE AZ
85392-5976
US

IV. Provider business mailing address

4234 E LEXINGTON AVE
GILBERT AZ
85234-0728
US

V. Phone/Fax

Practice location:
  • Phone: 623-474-2900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number10228
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: