Provider Demographics
NPI:1154754612
Name:PREVENTEC
Entity type:Organization
Organization Name:PREVENTEC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNETT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:509-783-1094
Mailing Address - Street 1:7701 W 4TH AVE APT E104
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-8540
Mailing Address - Country:US
Mailing Address - Phone:509-783-1094
Mailing Address - Fax:509-392-7150
Practice Address - Street 1:7701 W 4TH AVE APT E104
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-8540
Practice Address - Country:US
Practice Address - Phone:509-783-1094
Practice Address - Fax:509-392-7150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-19
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDE00008414122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty