Provider Demographics
NPI:1215033667
Name:MILES, LARRY WILLIS JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:WILLIS
Last Name:MILES
Suffix:JR
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 1:2105 DAWSON RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707-3207
Mailing Address - Country:US
Mailing Address - Phone:229-432-2213
Mailing Address - Fax:229-432-5888
Practice Address - Street 1:2105 DAWSON RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-3207
Practice Address - Country:US
Practice Address - Phone:229-432-2213
Practice Address - Fax:229-432-5888
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0131181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice