Provider Demographics
NPI:1063666964
Name:LARRY W LOVERIDGE, DMD, PLLC
Entity Type:Organization
Organization Name:LARRY W LOVERIDGE, DMD, PLLC
Other - Org Name:LARRY W LOVERIDGE, DMD, PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:W
Authorized Official - Last Name:LOVERIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:509-947-3862
Mailing Address - Street 1:1921 S ARTHUR ST
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99338-1856
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:509-735-9852
Practice Address - Street 1:1921 S ARTHUR ST
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99338-1856
Practice Address - Country:US
Practice Address - Phone:509-947-3862
Practice Address - Fax:509-735-9885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-05
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00007618261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5023577Medicaid