Provider Demographics
NPI:1982729307
Name:CALLOWAY, LARRY V (DDS)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:V
Last Name:CALLOWAY
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 1:965 BATTLEFIELD PKWY
Mailing Address - Street 2:
Mailing Address - City:FORT OGLETHORPE
Mailing Address - State:GA
Mailing Address - Zip Code:30742-3945
Mailing Address - Country:US
Mailing Address - Phone:706-866-8412
Mailing Address - Fax:706-861-3354
Practice Address - Street 1:965 BATTLEFIELD PKWY
Practice Address - Street 2:
Practice Address - City:FORT OGLETHORPE
Practice Address - State:GA
Practice Address - Zip Code:30742-3945
Practice Address - Country:US
Practice Address - Phone:706-866-8412
Practice Address - Fax:706-861-3354
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0103041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNDS0000004699OtherSTATE LICENSE NUMBER
GADN010304OtherSTATE LICENSE NUMBER
58-1780192OtherTIN