Provider Demographics
NPI:1285154435
Name:LARGE, KENT (DMD)
Entity type:Individual
Prefix:
First Name:KENT
Middle Name:
Last Name:LARGE
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 1:152 EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:GOLDENDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98620-3320
Mailing Address - Country:US
Mailing Address - Phone:360-301-9561
Mailing Address - Fax:
Practice Address - Street 1:617 E COLLINS ST
Practice Address - Street 2:
Practice Address - City:GOLDENDALE
Practice Address - State:WA
Practice Address - Zip Code:98620-9213
Practice Address - Country:US
Practice Address - Phone:509-773-5545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD10641122300000X
WADE60748917122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist