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NPI Code Detail

MEDICARE: DR. LARRY ALAN BACON DDS

MEDICARE: DR. LARRY ALAN BACON 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
11223S0112XOral and Maxillofacial Surgery (Dentist)DS2171TN

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
23726194OTHERTNMEDICARE GROUP NUMBER

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11609878388OTHERTNORGANIZATION NPI
31518969229OTHERTNORGANIZATION NPI
41972504389OTHERORGANIZATION NPI

General Provider Information

NPI Number : 1295736304
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. LARRY ALAN BACON DDS
Provider Business Mailing Address
First Line : 117 W SEVIER AVE
Second Line : SUITE 220
City : KINGSPORT
State : TN
Zip : 37660-3799
Country : US
Telephone Number : 423-224-3200
Fax Number : 423-224-3208
Provider Business Practice Location Address
First Line : 117 W SEVIER AVE
Second Line : SUITE 220
City : KINGSPORT
State : TN
Zip : 37660-3799
Country : US
Telephone Number : 423-224-3200
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/10/2005
Last Update Date : 03/01/2012

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Directions to “ DR. LARRY ALAN BACON DDS” Practice Location

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