Provider Demographics
NPI:1417977158
Name:SPENCE, TEDDY HENRY (DDS)
Entity Type:Individual
Prefix:DR
First Name:TEDDY
Middle Name:HENRY
Last Name:SPENCE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:TEDDY
Other - Middle Name:H
Other - Last Name:SPENCE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:3060 MAIN ST
Mailing Address - Street 2:PO BOX 819
Mailing Address - City:EXMORE
Mailing Address - State:VA
Mailing Address - Zip Code:23350-4736
Mailing Address - Country:US
Mailing Address - Phone:757-442-3313
Mailing Address - Fax:757-442-9677
Practice Address - Street 1:3060 MAIN ST
Practice Address - Street 2:
Practice Address - City:EXMORE
Practice Address - State:VA
Practice Address - Zip Code:23350-4736
Practice Address - Country:US
Practice Address - Phone:757-442-3313
Practice Address - Fax:757-442-9677
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010051911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0401005191OtherVA LICENSE NO
VA7817177Medicaid