Healthcare Provider Details

I. General information

NPI: 1871152397
Provider Name (Legal Business Name): SPENCER DANE UETZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2019
Last Update Date: 08/09/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 S. WASHINGTON ST.
GRAND FORKS ND
58201
US

IV. Provider business mailing address

PO BOX 13780
GRAND FORKS ND
58208
US

V. Phone/Fax

Practice location:
  • Phone: 701-732-7000
  • Fax: 217-545-6544
Mailing address:
  • Phone: 701-780-1891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number125074211
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number21128
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: