Provider Demographics
NPI:1699881300
Name:SPOON, MICHAEL EUGUNE (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:EUGUNE
Last Name:SPOON
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 1:255 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:VICTOR
Mailing Address - State:NY
Mailing Address - Zip Code:14564-1319
Mailing Address - Country:US
Mailing Address - Phone:585-924-0580
Mailing Address - Fax:
Practice Address - Street 1:255 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:VICTOR
Practice Address - State:NY
Practice Address - Zip Code:14564-1319
Practice Address - Country:US
Practice Address - Phone:585-924-0580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0434431223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01346469Medicaid