Provider Demographics
NPI:1164728606
Name:BROOKS, LARRY THOMAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:THOMAS
Last Name:BROOKS
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 1:4306 W EL PRADO BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-8405
Mailing Address - Country:US
Mailing Address - Phone:813-839-8730
Mailing Address - Fax:813-839-4707
Practice Address - Street 1:4306 W EL PRADO BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-8405
Practice Address - Country:US
Practice Address - Phone:813-839-8730
Practice Address - Fax:813-839-4707
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-01
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN4861122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist