Provider Demographics
NPI:1316033079
Name:PRESTON, LARRY AUSTIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:AUSTIN
Last Name:PRESTON
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 1:2348 VOLUNTEER PARKWAY
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620
Mailing Address - Country:US
Mailing Address - Phone:423-968-7871
Mailing Address - Fax:423-968-7871
Practice Address - Street 1:2348 VOLUNTEER PARKWAY
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620
Practice Address - Country:US
Practice Address - Phone:423-968-7871
Practice Address - Fax:423-968-7871
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS32041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0161023OtherBCBS TN
VA036969OtherANTHEMBCBS VA
TN3225468Medicaid