MEDICARE: LARRY HEGGERNESS SOCIAL PURPOSE PROFESSIONAL CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	DE00003686	WA

General Provider Information

NPI Number	:	1124365796
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LARRY HEGGERNESS SOCIAL PURPOSE PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	6720 FORT DENT WAY STE 120
Second Line	:
City	:	TUKWILA
State	:	WA
Zip	:	98188-2580
Country	:	US
Telephone Number	:	206-242-4121
Fax Number	:	206-242-4113

Provider Business Practice Location Address
First Line	:	6720 FORT DENT WAY STE 120
Second Line	:
City	:	TUKWILA
State	:	WA
Zip	:	98188-2580
Country	:	US
Telephone Number	:	206-242-4121
Fax Number	:	206-242-4113

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. LARRY K HEGGERNESS
Credential	:	DDS
Telephone Number	:	206-242-4121

Provider Enumeration Date	:	01/15/2013
Last Update Date	:	01/15/2013

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