Healthcare Provider Details

I. General information

NPI: 1366409807
Provider Name (Legal Business Name): LAWRENCE LUTHER COPENHAVER III DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: LARRY L COPENHAVER DMD

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 03/27/2025
Certification Date: 03/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1295 W FAIRFIELD DR
PENSACOLA FL
32501-1107
US

IV. Provider business mailing address

2315 W JACKSON ST
PENSACOLA FL
32505-7552
US

V. Phone/Fax

Practice location:
  • Phone: 850-912-8880
  • Fax: 850-912-8779
Mailing address:
  • Phone: 850-436-4630
  • Fax: 850-436-2095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberDN08846
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN8846
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: