Healthcare Provider Details

I. General information

NPI: 1891765822
Provider Name (Legal Business Name): LON PATRICK SPAIN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 09/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 ALEXANDER STREET
CEDAR GROVE WV
25039
US

IV. Provider business mailing address

PO BOX 1680
HUNTINGTON WV
25717-1680
US

V. Phone/Fax

Practice location:
  • Phone: 304-595-1770
  • Fax:
Mailing address:
  • Phone: 304-525-3334
  • Fax: 304-697-2086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3400
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: