MEDICARE: STEVEN R. SPIVAK, DMD, INC

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	62528	CA

General Provider Information

NPI Number	:	1750780110
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STEVEN R. SPIVAK, DMD, INC

Provider Business Mailing Address
First Line	:	5410 RHODES AVE
Second Line	:	102
City	:	VALLEY VILLAGE
State	:	CA
Zip	:	91607-1669
Country	:	US
Telephone Number	:	818-687-3111
Fax Number	:

Provider Business Practice Location Address
First Line	:	13114 SHERMAN WAY
Second Line	:
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91605-4645
Country	:	US
Telephone Number	:	818-982-6162
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. STEVEN SPIVAK
Credential	:	DMD
Telephone Number	:	818-687-3111

Provider Enumeration Date	:	08/21/2014
Last Update Date	:	08/21/2014

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