Basic Information
| Provider Information | |||||||||
| NPI: | 1851487987 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURNETT | ||||||||
| FirstName: | SPENCER | ||||||||
| MiddleName: | DREW | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PHOENIX INDIAN MEDICAL CENTER ATT: DENTAL | ||||||||
| Address2: | 4212 N. 16TH STREET | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022631200 | ||||||||
| FaxNumber: | 6022631608 | ||||||||
| Practice Location | |||||||||
| Address1: | PHOENIX INDIAN MEDICAL CENTER ATT: DENTAL | ||||||||
| Address2: | 4212 N. 16TH STREET | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022631200 | ||||||||
| FaxNumber: | 6022631608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0221X | DN12282 | FL | Y | Dental Providers | Dentist | Pediatric Dentistry |
ID Information
| ID | Type | State | Issuer | Description | AZ0419140 | 01 | AZ | BLUE CROSS/BLUE SHIELD | OTHER | 621393 | 05 | AZ | MEDICAID |