Provider Demographics
NPI:1467530840
Name:LEGACIE, LARRY D (DDS)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:D
Last Name:LEGACIE
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:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:EDMORE
Mailing Address - State:ND
Mailing Address - Zip Code:58330-0247
Mailing Address - Country:US
Mailing Address - Phone:701-644-2254
Mailing Address - Fax:701-644-2254
Practice Address - Street 1:323 A MAIN STREET
Practice Address - Street 2:
Practice Address - City:EDMORE
Practice Address - State:ND
Practice Address - Zip Code:58330-0247
Practice Address - Country:US
Practice Address - Phone:701-644-2254
Practice Address - Fax:701-644-2254
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1611122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND40723Medicaid
ND1611OtherDENTAL STATE LICENSE