Provider Demographics
NPI:1780050971
Name:FADDIS, SPENCER J (DDS)
Entity type:Individual
Prefix:
First Name:SPENCER
Middle Name:J
Last Name:FADDIS
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 1:17000 RED HILL AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-5626
Mailing Address - Country:US
Mailing Address - Phone:714-845-8890
Mailing Address - Fax:949-474-1495
Practice Address - Street 1:10870 W CHARLESTON BLVD
Practice Address - Street 2:170
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89135-1158
Practice Address - Country:US
Practice Address - Phone:702-254-6412
Practice Address - Fax:702-254-9558
Is Sole Proprietor?:No
Enumeration Date:2015-08-11
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6658122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist