Healthcare Provider Details

I. General information

NPI: 1447363957
Provider Name (Legal Business Name): GLENN D SPRADLIN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 04/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 CARTER AVE
ASHLAND KY
41101-7737
US

IV. Provider business mailing address

PO BOX 1587
ASHLAND KY
41105-1587
US

V. Phone/Fax

Practice location:
  • Phone: 606-329-1440
  • Fax: 606-329-2441
Mailing address:
  • Phone: 606-329-1440
  • Fax: 606-329-2441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number5782
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number5782
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: