MEDICARE: DR. LARRY CHAMBERS D.D.S.

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	122300000X	Dentist	DS4211	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	803388	OTHER	TN	UCCI
2	0149768	OTHER	TN	BCBS CORP ID#
3	0132345	OTHER	TN	BCBS/TN

General Provider Information

NPI Number	:	1205912219
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LARRY CHAMBERS D.D.S.

Provider Business Mailing Address
First Line	:	35 RIDGECREST DR.
Second Line	:
City	:	JACKSON
State	:	TN
Zip	:	38305
Country	:	US
Telephone Number	:	731-668-8907
Fax Number	:

Provider Business Practice Location Address
First Line	:	3067 N HIGHLAND AVE
Second Line	:
City	:	JACKSON
State	:	TN
Zip	:	38305-3411
Country	:	US
Telephone Number	:	731-668-7916
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/31/2006
Last Update Date	:	07/08/2007

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