Provider Demographics
NPI:1083732747
Name:LARRY E.BAUCOM, D.D.S., P.A.
Entity Type:Organization
Organization Name:LARRY E.BAUCOM, D.D.S., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:E
Authorized Official - Last Name:BAUCOM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:910-295-1010
Mailing Address - Street 1:PO BOX 789
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28370-0789
Mailing Address - Country:US
Mailing Address - Phone:910-295-1010
Mailing Address - Fax:910-295-1367
Practice Address - Street 1:305 PAGE RD.
Practice Address - Street 2:SUITE 2
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374
Practice Address - Country:US
Practice Address - Phone:910-295-1010
Practice Address - Fax:910-295-1367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3258261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental