Provider Demographics
NPI:1295736304
Name:BACON, LARRY ALAN (DDS)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:ALAN
Last Name:BACON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:L
Other - Middle Name:ALAN
Other - Last Name:BACON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:117 W SEVIER AVE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3799
Mailing Address - Country:US
Mailing Address - Phone:423-224-3200
Mailing Address - Fax:423-224-3208
Practice Address - Street 1:117 W SEVIER AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3799
Practice Address - Country:US
Practice Address - Phone:423-224-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS21711223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1609878388OtherORGANIZATION NPI
TN3726194OtherMEDICARE GROUP NUMBER
TN1518969229OtherORGANIZATION NPI
1972504389OtherORGANIZATION NPI
1972504389OtherORGANIZATION NPI
TN3726194OtherMEDICARE GROUP NUMBER