1518076793 NPI number — MR. RAYMOND WENDEL SPORE SR. DDS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518076793 NPI number — MR. RAYMOND WENDEL SPORE SR. DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPORE
Provider First Name:
RAYMOND
Provider Middle Name:
WENDEL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
SR.
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SPORE
Provider Other First Name:
RAYMOND
Provider Other Middle Name:
W
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DDS A DENTAL CORPORA
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1518076793
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
635 ANDERSON RD
Provider Second Line Business Mailing Address:
STE #14
Provider Business Mailing Address City Name:
DAVIS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95616
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-756-0953
Provider Business Mailing Address Fax Number:
530-756-3588

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
635 ANDERSON RD
Provider Second Line Business Practice Location Address:
STE #14
Provider Business Practice Location Address City Name:
DAVIS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95616
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-756-0953
Provider Business Practice Location Address Fax Number:
530-756-0953
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  18020 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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