MEDICARE: DR. TERRY MICHAEL SPENCE DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	015924	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	27-1535914	OTHER	MO	TAX ID #

General Provider Information

NPI Number	:	1215259429
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TERRY MICHAEL SPENCE DDS

Provider Business Mailing Address
First Line	:	2103 BROADWAY ST
Second Line	:
City	:	CAPE GIRARDEAU
State	:	MO
Zip	:	63701-4401
Country	:	US
Telephone Number	:	573-332-7223
Fax Number	:	573-334-7379

Provider Business Practice Location Address
First Line	:	2103 BROADWAY ST
Second Line	:
City	:	CAPE GIRARDEAU
State	:	MO
Zip	:	63701-4401
Country	:	US
Telephone Number	:	573-332-7223
Fax Number	:	573-334-7379

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/16/2010
Last Update Date	:	07/05/2011

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