Healthcare Provider Details

I. General information

NPI: 1669760823
Provider Name (Legal Business Name): SPENCER BJARNASON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2011
Last Update Date: 07/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3622 WILLIAMS DR STE 3
GEORGETOWN TX
78628-2508
US

IV. Provider business mailing address

3622 WILLIAMS DR STE 3
GEORGETOWN TX
78628-2508
US

V. Phone/Fax

Practice location:
  • Phone: 512-948-7624
  • Fax: 512-948-7627
Mailing address:
  • Phone: 512-948-7624
  • Fax: 512-948-7627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number27220
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number10509
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number27220
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: