Provider Demographics
NPI:1518948132
Name:LARREAU, BRAD A (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:A
Last Name:LARREAU
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 1:2218 BRYANT ST
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037
Mailing Address - Country:US
Mailing Address - Phone:316-789-8926
Mailing Address - Fax:
Practice Address - Street 1:22D MEDICAL GROUP/SGQ
Practice Address - Street 2:57950 LEAVENWORTH ST
Practice Address - City:MCCONNELL AFB
Practice Address - State:KS
Practice Address - Zip Code:67221-3506
Practice Address - Country:US
Practice Address - Phone:316-759-5181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS60461122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist