Healthcare Provider Details

I. General information

NPI: 1710967047
Provider Name (Legal Business Name): JOHN WALTER HARGRAVE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JOHN WALTER HARGRAVE D.D.S

II. Dates (important events)

Enumeration Date: 01/20/2006
Last Update Date: 07/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

760 EAST AVE BLDG 3911 SUITE B
PENSACOLA FL
32508-5136
US

IV. Provider business mailing address

8 STAR LAKE DR
PENSACOLA FL
32507-3410
US

V. Phone/Fax

Practice location:
  • Phone: 850-377-4593
  • Fax: 850-452-8892
Mailing address:
  • Phone: 850-377-4593
  • Fax: 850-452-8892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN 5392
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: