Healthcare Provider Details

I. General information

NPI: 1134181399
Provider Name (Legal Business Name): CLIFFORD CARL SPRUNG DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W28550 SUSSEX RD
MERTON WI
53056-0003
US

IV. Provider business mailing address

PO BOX 3
MERTON WI
53056-0003
US

V. Phone/Fax

Practice location:
  • Phone: 262-538-0892
  • Fax: 262-538-2695
Mailing address:
  • Phone: 262-538-0892
  • Fax: 262-538-2695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3018
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: