Provider Demographics
NPI:1861417651
Name:GILLENWATER, LARRY HEATH (DDS)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:HEATH
Last Name:GILLENWATER
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 1:1335 E CENTER ST
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37664-2489
Mailing Address - Country:US
Mailing Address - Phone:423-247-5125
Mailing Address - Fax:423-246-2564
Practice Address - Street 1:1335 E CENTER ST
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37664-2489
Practice Address - Country:US
Practice Address - Phone:423-247-5125
Practice Address - Fax:423-246-2564
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS0000002549122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist