Individual
DR. LARRY ALAN BACON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
117 W SEVIER AVE, SUITE 220, KINGSPORT, TN 37660-3799
(423) 224-3200
Mailing address
117 W SEVIER AVE, SUITE 220, KINGSPORT, TN 37660-3799
(423) 224-3200
(423) 224-3208
Taxonomy
Speciality
Code
Description
License number
State
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
DS2171
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1518969229
ORGANIZATION NPI
TN
01
—
1609878388
ORGANIZATION NPI
TN
01
—
1972504389
ORGANIZATION NPI
—
01
—
3726194
MEDICARE GROUP NUMBER
TN
Enumeration date
08/10/2005
Last updated
03/01/2012
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