Provider Demographics
NPI:1487893988
Name:WADE, SPENCER GLEN (DDS)
Entity type:Individual
Prefix:
First Name:SPENCER
Middle Name:GLEN
Last Name:WADE
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 1:5139 S. 1900 W.
Mailing Address - Street 2:
Mailing Address - City:ROY
Mailing Address - State:UT
Mailing Address - Zip Code:84067
Mailing Address - Country:US
Mailing Address - Phone:801-773-7721
Mailing Address - Fax:801-773-1657
Practice Address - Street 1:5139 S 1900 W
Practice Address - Street 2:
Practice Address - City:ROY
Practice Address - State:UT
Practice Address - Zip Code:84067-2997
Practice Address - Country:US
Practice Address - Phone:801-773-7721
Practice Address - Fax:801-773-1657
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7033505-9921-89031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice