Healthcare Provider Details

I. General information

NPI: 1316396419
Provider Name (Legal Business Name): SPENCER WADE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2016
Last Update Date: 09/07/2021
Certification Date: 09/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 E 24TH ST
NEW YORK NY
10010-4020
US

IV. Provider business mailing address

20 WATERSIDE PLZ APT 36G
NEW YORK NY
10010-2618
US

V. Phone/Fax

Practice location:
  • Phone: 517-285-8734
  • Fax:
Mailing address:
  • Phone: 517-285-8734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number3705
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number10310
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License NumberO61371
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: