Healthcare Provider Details

I. General information

NPI: 1346949401
Provider Name (Legal Business Name): SPENCER BRAY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2023
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 S 8TH AVE STOP 8088
POCATELLO ID
83209-8088
US

IV. Provider business mailing address

2300 SIENNA DR
POCATELLO ID
83201-5186
US

V. Phone/Fax

Practice location:
  • Phone: 208-282-5834
  • Fax:
Mailing address:
  • Phone: 208-282-5834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8181919
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: