Provider Demographics
NPI:1861230245
Name:RASMUSSON, SPENCER JAMES
Entity type:Individual
Prefix:
First Name:SPENCER
Middle Name:JAMES
Last Name:RASMUSSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23125 BOB WHITE DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73025-9441
Mailing Address - Country:US
Mailing Address - Phone:435-592-1654
Mailing Address - Fax:
Practice Address - Street 1:7019 W HEFNER RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73162-4712
Practice Address - Country:US
Practice Address - Phone:435-592-1654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-18
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK79371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty