MEDICARE: DR. JULIE CUSTRED SPIVEY DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	5764	AL
2	1223P0221X	Pediatric Dentistry	10515	NC

General Provider Information

NPI Number	:	1396057006
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JULIE CUSTRED SPIVEY DMD

Provider Business Mailing Address
First Line	:	4901 N TRYON ST
Second Line	:	UNIT A
City	:	CHARLOTTE
State	:	NC
Zip	:	28213-7076
Country	:	US
Telephone Number	:	704-921-0204
Fax Number	:

Provider Business Practice Location Address
First Line	:	4901 N TRYON ST
Second Line	:	UNIT A
City	:	CHARLOTTE
State	:	NC
Zip	:	28213-7076
Country	:	US
Telephone Number	:	704-921-0204
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/10/2010
Last Update Date	:	09/07/2016

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