Provider Demographics
NPI:1548621675
Name:SPENCER, DARYL (DDS)
Entity type:Individual
Prefix:
First Name:DARYL
Middle Name:
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:USA DENTAL HEALTH ACTIVITY
Mailing Address - Street 2:4301 WILSON STREET
Mailing Address - City:FORT SILL
Mailing Address - State:OK
Mailing Address - Zip Code:73503-0001
Mailing Address - Country:US
Mailing Address - Phone:580-558-2795
Mailing Address - Fax:
Practice Address - Street 1:COWAN DENTAL CLINIC
Practice Address - Street 2:605 RANDOLPH RD.
Practice Address - City:FORT SILL
Practice Address - State:OK
Practice Address - Zip Code:73503-0001
Practice Address - Country:US
Practice Address - Phone:580-442-5108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-17
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD46461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice