Healthcare Provider Details

I. General information

NPI: 1952235012
Provider Name (Legal Business Name): SPENCER GENTRY MYLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2026
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 N LITCHFIELD ROAD BYP STE 1
LITCHFIELD PARK AZ
85340-5061
US

IV. Provider business mailing address

16601 N 75TH AVE UNIT 2107
PEORIA AZ
85382-5041
US

V. Phone/Fax

Practice location:
  • Phone: 623-935-5055
  • Fax:
Mailing address:
  • Phone: 208-995-0319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD012855
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: