Provider Demographics
NPI:1528087301
Name:HARGREAVES, LARRY C (DDS)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:C
Last Name:HARGREAVES
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 NEOSHO ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:KS
Mailing Address - Zip Code:66839-1926
Mailing Address - Country:US
Mailing Address - Phone:620-364-8414
Mailing Address - Fax:620-364-8416
Practice Address - Street 1:314 NEOSHO ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:KS
Practice Address - Zip Code:66839-1926
Practice Address - Country:US
Practice Address - Phone:620-364-8414
Practice Address - Fax:620-364-8416
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS4836122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100096690BMedicaid
KS100096690Medicaid