Provider Demographics
NPI:1861497067
Name:BETSWORTH, LARRE L (DDS)
Entity type:Individual
Prefix:
First Name:LARRE
Middle Name:L
Last Name:BETSWORTH
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 1:2301 SW 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66606-1759
Mailing Address - Country:US
Mailing Address - Phone:785-233-1162
Mailing Address - Fax:785-233-4169
Practice Address - Street 1:2301 SW 6TH AVE
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66606-1759
Practice Address - Country:US
Practice Address - Phone:785-233-1162
Practice Address - Fax:785-233-4169
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-15
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS65501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
785405OtherUNITED CONCORDIA-TRICARE
KS22957OtherBLUECROSS BLUE SHIELD