=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225426729
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SCOTT SPENCER DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2015
-----------------------------------------------------
Last Update Date | 01/06/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10075 S JOG RD STE 108
-----------------------------------------------------
City | BOYNTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33437-3532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-738-9007
-----------------------------------------------------
Fax | 561-738-9963
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10075 S JOG RD STE 108
-----------------------------------------------------
City | BOYNTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33437-3532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-738-9007
-----------------------------------------------------
Fax | 561-738-9963
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | DN19980
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------