Provider Demographics
NPI:1316133499
Name:BEVERLY A LARGENT, D.M.D.
Entity type:Organization
Organization Name:BEVERLY A LARGENT, D.M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:LARGENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-554-5437
Mailing Address - Street 1:3008 OREGON ST
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-5651
Mailing Address - Country:US
Mailing Address - Phone:270-554-5437
Mailing Address - Fax:270-554-5236
Practice Address - Street 1:3008 OREGON ST
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-5651
Practice Address - Country:US
Practice Address - Phone:270-554-5437
Practice Address - Fax:270-554-5236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-21
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY54661223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100001640Medicaid
KY60054665Medicaid