Provider Demographics
NPI:1124611801
Name:SPENCER, EVAN M (DDS)
Entity type:Individual
Prefix:DR
First Name:EVAN
Middle Name:M
Last Name:SPENCER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 E RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-2006
Mailing Address - Country:US
Mailing Address - Phone:585-974-5045
Mailing Address - Fax:
Practice Address - Street 1:313 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ALBION
Practice Address - State:NY
Practice Address - Zip Code:14411-1602
Practice Address - Country:US
Practice Address - Phone:585-589-4325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-14
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY0625951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program