Basic Information
| Provider Information | |||||||||
| NPI: | 1891765822 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPAIN | ||||||||
| FirstName: | LON | ||||||||
| MiddleName: | PATRICK | ||||||||
| NamePrefix: | |||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1680 | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257171680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045253334 | ||||||||
| FaxNumber: | 3046972086 | ||||||||
| Practice Location | |||||||||
| Address1: | 408 ALEXANDER STREET | ||||||||
| Address2: | |||||||||
| City: | CEDAR GROVE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045951770 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2006 | ||||||||
| LastUpdateDate: | 09/17/2013 | ||||||||
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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 | 122300000X | 3400 | WV | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 7100174300 | 05 | KY | MEDICAID | 2036862 | 05 | OH | MEDICAID | 7805006000 | 05 | WV | MEDICAID |