Healthcare Provider Details

I. General information

NPI: 1528087301
Provider Name (Legal Business Name): LARRY C HARGREAVES DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 NEOSHO ST
BURLINGTON KS
66839-1926
US

IV. Provider business mailing address

314 NEOSHO ST
BURLINGTON KS
66839-1926
US

V. Phone/Fax

Practice location:
  • Phone: 620-364-8414
  • Fax: 620-364-8416
Mailing address:
  • Phone: 620-364-8414
  • Fax: 620-364-8416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number4836
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4836
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: