Provider Demographics
NPI:1194960161
Name:PEVNY, LARRY LEE (DENTURIST)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:LEE
Last Name:PEVNY
Suffix:
Gender:M
Credentials:DENTURIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-4532
Mailing Address - Country:US
Mailing Address - Phone:360-659-6300
Mailing Address - Fax:360-691-7881
Practice Address - Street 1:619 CEDAR AVE
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-4532
Practice Address - Country:US
Practice Address - Phone:360-659-6300
Practice Address - Fax:360-691-7881
Is Sole Proprietor?:No
Enumeration Date:2008-12-04
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN00000045122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1336278910OtherORGANIZATIONAL NPI NUMBER