=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710622428
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELLIOTT SPENNER DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2022
-----------------------------------------------------
Last Update Date | 09/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 206 WILMAR AVE
-----------------------------------------------------
City | GRAND ISLAND
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68803-3559
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-384-7500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2750 COUNTY ROAD 21
-----------------------------------------------------
City | BENNINGTON
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68007-8097
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-216-4211
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 7852
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 2479
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------