Healthcare Provider Details

I. General information

NPI: 1518948132
Provider Name (Legal Business Name): BRAD A LARREAU DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 12/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22D MEDICAL GROUP/SGQ 57950 LEAVENWORTH ST
MCCONNELL AFB KS
67221-3506
US

IV. Provider business mailing address

2218 BRYANT ST
DERBY KS
67037
US

V. Phone/Fax

Practice location:
  • Phone: 316-759-5181
  • Fax:
Mailing address:
  • Phone: 316-789-8926
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number60461
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: