Provider Demographics
NPI:1366409807
Name:COPENHAVER, LAWRENCE LUTHER III (DMD)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:LUTHER
Last Name:COPENHAVER
Suffix:III
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:LARRY
Other - Middle Name:L
Other - Last Name:COPENHAVER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:2315 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32505-7552
Mailing Address - Country:US
Mailing Address - Phone:850-436-4630
Mailing Address - Fax:850-436-2095
Practice Address - Street 1:1295 W FAIRFIELD DR
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-1107
Practice Address - Country:US
Practice Address - Phone:850-912-8880
Practice Address - Fax:850-912-8779
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN088461223D0001X
FLDN8846122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL077307700Medicaid
FL60314ZMedicare ID - Type Unspecified
FLDN8846Medicare UPIN