=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710967047
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN WALTER HARGRAVE D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2006
-----------------------------------------------------
Last Update Date | 07/30/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 760 EAST AVE BLDG 3911 SUITE B
-----------------------------------------------------
City | PENSACOLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32508-5136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-377-4593
-----------------------------------------------------
Fax | 850-452-8892
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8 STAR LAKE DR
-----------------------------------------------------
City | PENSACOLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32507-3410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-377-4593
-----------------------------------------------------
Fax | 850-452-8892
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN 5392
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------