Provider Demographics
NPI:1013025121
Name:BLOODSWORTH, LARRY MIKE (DDS)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:MIKE
Last Name:BLOODSWORTH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 MAGNOLIA DRIVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701
Mailing Address - Country:US
Mailing Address - Phone:903-595-2707
Mailing Address - Fax:
Practice Address - Street 1:1001 MAGNOLIA DRIVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701
Practice Address - Country:US
Practice Address - Phone:903-595-2707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11305122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist