Provider Demographics
NPI:1659322121
Name:FERGUSON, LARRY JETHRO (DMD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:JETHRO
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1812 WALLACE SCHOOL ROAD,
Mailing Address - Street 2:SUITE 400
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-4517
Mailing Address - Country:US
Mailing Address - Phone:843-571-4411
Mailing Address - Fax:843-571-1801
Practice Address - Street 1:1812 WALLACE SCHOOL ROAD,
Practice Address - Street 2:SUITE 400
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-4517
Practice Address - Country:US
Practice Address - Phone:843-571-4411
Practice Address - Fax:843-571-1801
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ22627Medicaid