Healthcare Provider Details

I. General information

NPI: 1346556040
Provider Name (Legal Business Name): SHAMAINE SPENCER D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2010
Last Update Date: 10/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 MEDICAL CENTER RD
EDGEWOOD NM
87015-7086
US

IV. Provider business mailing address

8 MEDICAL CENTER RD P.O. BOX 2606
EDGEWOOD NM
87015-7086
US

V. Phone/Fax

Practice location:
  • Phone: 505-224-8718
  • Fax: 505-224-8737
Mailing address:
  • Phone: 505-224-8718
  • Fax: 505-224-8737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD3325
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: