MEDICARE: FRED V HARGIS JR. DDS

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	4835	KS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	08929	OTHER	KS	BCBS

General Provider Information

NPI Number	:	1366413791
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FRED V HARGIS JR. DDS

Provider Business Mailing Address
First Line	:	311 N MILL ST
Second Line	:
City	:	MINNEAPOLIS
State	:	KS
Zip	:	67467
Country	:	US
Telephone Number	:	785-392-2194
Fax Number	:	785-392-3231

Provider Business Practice Location Address
First Line	:	311 N MILL ST
Second Line	:
City	:	MINNEAPOLIS
State	:	KS
Zip	:	67467
Country	:	US
Telephone Number	:	785-392-2194
Fax Number	:	785-392-3231

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

Provider Enumeration Date	:	02/01/2006
Last Update Date	:	07/08/2007

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