Provider Demographics
NPI:1811096399
Name:BREEDING, LARRY C (DMD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:C
Last Name:BREEDING
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:UNIVERSITY OF MISSISSIPPI SCHOOL OF DENTISTRY
Mailing Address - Street 2:2500 NORTH STATE STREET
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4505
Mailing Address - Country:US
Mailing Address - Phone:601-984-6030
Mailing Address - Fax:601-984-6039
Practice Address - Street 1:UNIVERSITY OF MISSISSIPPI SCHOOL OF DENTISTRY
Practice Address - Street 2:2500 NORTH STATE STREET
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4505
Practice Address - Country:US
Practice Address - Phone:601-984-6030
Practice Address - Fax:601-984-6039
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3077-981223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS660284Medicaid