Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 019028468 | IL |
Y | 1223P0300X | Periodontist | 11292 | TN |
NPI | 1003198680 |
---|---|
Provider Name | Dr. Spencer John Shoff |
First Address | Knoxville, TN 37909-1284 |
Second Address | Knoxville, TN 37909-1284 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/09/2011 |
Last Update Date | 02/08/2020 |