Provider Demographics
NPI:1528729555
Name:SPD LLC
Entity type:Organization
Organization Name:SPD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRESHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:318-855-1426
Mailing Address - Street 1:1416 HAZEL ST
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:LA
Mailing Address - Zip Code:71001-4114
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1416 HAZEL ST
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:LA
Practice Address - Zip Code:71001-4114
Practice Address - Country:US
Practice Address - Phone:318-855-1426
Practice Address - Fax:318-579-5038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-03
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental