Healthcare Provider Details

I. General information

NPI: 1700097839
Provider Name (Legal Business Name): LARINDA LEA HLAVACEK D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 E 25TH ST
KANSAS CITY MO
64108-2716
US

IV. Provider business mailing address

2115 W 79TH ST
PRAIRIE VILLAGE KS
66208-3825
US

V. Phone/Fax

Practice location:
  • Phone: 816-235-2121
  • Fax:
Mailing address:
  • Phone: 913-901-8410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2007002278
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: