Provider Demographics
NPI:1578765582
Name:SPENCE, KENNETH R (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:R
Last Name:SPENCE
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 1:2700 EARL RUDDER FWY S
Mailing Address - Street 2:SUITE 1900
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-5010
Mailing Address - Country:US
Mailing Address - Phone:979-696-4511
Mailing Address - Fax:
Practice Address - Street 1:2700 EARL RUDDER FWY S
Practice Address - Street 2:SUITE 1900
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-5010
Practice Address - Country:US
Practice Address - Phone:979-696-4511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX148921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX82D691OtherBCBS PROVIDER #