=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477701951
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPENCER CREEK DENTAL CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2008
-----------------------------------------------------
Last Update Date | 09/08/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5600 MEXICO RD SUITE #20
-----------------------------------------------------
City | SAINT PETERS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63376-1660
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-928-0880
-----------------------------------------------------
Fax | 636-928-6866
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5600 MEXICO RD SUITE #20
-----------------------------------------------------
City | SAINT PETERS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63376-1660
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-928-0880
-----------------------------------------------------
Fax | 636-928-6866
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER/OWNER
-----------------------------------------------------
Name | DR. MONROE MITCHELL GINSBURG
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 636-928-0880
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DE013782
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------