Healthcare Provider Details

I. General information

NPI: 1629149851
Provider Name (Legal Business Name): SPENCER JOHN TASKER D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 07/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8201 GOLF COURSE RD NW STE C-3
ALBUQUERQUE NM
87120-5842
US

IV. Provider business mailing address

7224 VIA CONTENTA NE
ALBUQUERQUE NM
87113-1343
US

V. Phone/Fax

Practice location:
  • Phone: 505-892-9010
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD2829
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: