Provider Demographics
NPI:1316187016
Name:CRISAFULLI, LARRY A (DDS)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:A
Last Name:CRISAFULLI
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 1:1121 W MICHIGAN STREET
Mailing Address - Street 2:DS307B
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-5186
Mailing Address - Country:US
Mailing Address - Phone:202-332-2291
Mailing Address - Fax:
Practice Address - Street 1:1121 W MICHIGAN STREET
Practice Address - Street 2:DS307B
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5186
Practice Address - Country:US
Practice Address - Phone:317-278-3632
Practice Address - Fax:317-274-2603
Is Sole Proprietor?:No
Enumeration Date:2009-02-20
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012038A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice