Provider Demographics
NPI:1487675690
Name:TEBAY, HARRY TALBOTT (DDS)
Entity Type:Individual
Prefix:
First Name:HARRY
Middle Name:TALBOTT
Last Name:TEBAY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 GRAND CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:WV
Mailing Address - Zip Code:26105-1052
Mailing Address - Country:US
Mailing Address - Phone:304-295-8282
Mailing Address - Fax:304-295-8282
Practice Address - Street 1:1301 GRAND CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:WV
Practice Address - Zip Code:26105-1052
Practice Address - Country:US
Practice Address - Phone:304-295-8282
Practice Address - Fax:304-295-8282
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0136045000Medicaid