Provider Demographics
NPI:1073503488
Name:LARKIN, THOMAS J III (DMD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:LARKIN
Suffix:III
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 1:513 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ANNA
Mailing Address - State:IL
Mailing Address - Zip Code:62906-1668
Mailing Address - Country:US
Mailing Address - Phone:618-833-4471
Mailing Address - Fax:618-833-4900
Practice Address - Street 1:513 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ANNA
Practice Address - State:IL
Practice Address - Zip Code:62906-1668
Practice Address - Country:US
Practice Address - Phone:618-833-4471
Practice Address - Fax:618-833-4900
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2016-04-25
Deactivation Date:2006-03-31
Deactivation Code:
Reactivation Date:2006-05-01
Provider Licenses
StateLicense IDTaxonomies
IL019-022104122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019-022104Medicaid