Healthcare Provider Details

I. General information

NPI: 1760961817
Provider Name (Legal Business Name): SPIKA DENTAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2018
Last Update Date: 08/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 W LINE ST
BISHOP CA
93514-3413
US

IV. Provider business mailing address

PO BOX 2185
MAMMOTH LAKES CA
93546-2185
US

V. Phone/Fax

Practice location:
  • Phone: 253-651-0705
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number102998
License Number StateCA

VIII. Authorized Official

Name: DR. BRADFORD CHARLES SPIKA
Title or Position: PRESIDENT
Credential: DMD
Phone: 253-651-0705