Healthcare Provider Details

I. General information

NPI: 1801178256
Provider Name (Legal Business Name): JOSHUA THOMAS SPARKS D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2011
Last Update Date: 04/11/2023
Certification Date: 04/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG 38801, ACADEMIC DRIVE
FORT GORDON GA
30905
US

IV. Provider business mailing address

3740 S 14TH STREET USA DENTAL HEALTH ACTIVITY
JOINT BASE LEWIS-MCCHORD WA
98433
US

V. Phone/Fax

Practice location:
  • Phone: 706-787-5738
  • Fax: 706-787-2072
Mailing address:
  • Phone: 253-967-5271
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE60244154
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDE60244154
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: