Provider Demographics
NPI:1710967047
Name:HARGRAVE, JOHN WALTER (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WALTER
Last Name:HARGRAVE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:WALTER
Other - Last Name:HARGRAVE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:8 STAR LAKE DR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32507-3410
Mailing Address - Country:US
Mailing Address - Phone:850-377-4593
Mailing Address - Fax:850-452-8892
Practice Address - Street 1:760 EAST AVE
Practice Address - Street 2:BLDG 3911 SUITE B
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32508-5136
Practice Address - Country:US
Practice Address - Phone:850-377-4593
Practice Address - Fax:850-452-8892
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 5392122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist