Provider Demographics
NPI:1124365796
Name:LARRY HEGGERNESS SOCIAL PURPOSE PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:LARRY HEGGERNESS SOCIAL PURPOSE PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:K
Authorized Official - Last Name:HEGGERNESS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:206-242-4121
Mailing Address - Street 1:6720 FORT DENT WAY STE 120
Mailing Address - Street 2:
Mailing Address - City:TUKWILA
Mailing Address - State:WA
Mailing Address - Zip Code:98188-2580
Mailing Address - Country:US
Mailing Address - Phone:206-242-4121
Mailing Address - Fax:206-242-4113
Practice Address - Street 1:6720 FORT DENT WAY STE 120
Practice Address - Street 2:
Practice Address - City:TUKWILA
Practice Address - State:WA
Practice Address - Zip Code:98188-2580
Practice Address - Country:US
Practice Address - Phone:206-242-4121
Practice Address - Fax:206-242-4113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-15
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000036861223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty