Healthcare Provider Details

I. General information

NPI: 1417937244
Provider Name (Legal Business Name): THOMAS RAY SPRADLIN DENTAL OFFICER
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 CHESAPEAKE TRL
CANTONMENT FL
32533-4571
US

IV. Provider business mailing address

845 CHESAPEAKE TRL
CANTONMENT FL
32533-4571
US

V. Phone/Fax

Practice location:
  • Phone: 850-452-8970
  • Fax: 850-452-8978
Mailing address:
  • Phone: 850-452-8970
  • Fax: 850-452-8978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2757
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: