Provider Demographics
NPI:1447363957
Name:SPRADLIN, GLENN D (DMD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:D
Last Name:SPRADLIN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1587
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-1587
Mailing Address - Country:US
Mailing Address - Phone:606-329-1440
Mailing Address - Fax:606-329-2441
Practice Address - Street 1:2000 CARTER AVE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-7737
Practice Address - Country:US
Practice Address - Phone:606-329-1440
Practice Address - Fax:606-329-2441
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY57821223P0221X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60057825Medicaid