Healthcare Provider Details

I. General information

NPI: 1336524594
Provider Name (Legal Business Name): DJ AND AK SPENCER DMD PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2015
Last Update Date: 07/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22205 MERIDIAN AVE E SUITE 109
GRAHAM WA
98338
US

IV. Provider business mailing address

22205 MERIDIAN AVE E SUITE 109
GRAHAM WA
98338
US

V. Phone/Fax

Practice location:
  • Phone: 253-875-6599
  • Fax:
Mailing address:
  • Phone: 253-875-6599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE00010963
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. ANNA K SPENCER
Title or Position: DENTIST
Credential: DMD
Phone: 253-279-1877