Provider Demographics
NPI:1518121284
Name:NILLISSEN, LARRY LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:LEE
Last Name:NILLISSEN
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:PO BOX 206
Mailing Address - Street 2:409A MAIN ST
Mailing Address - City:BIRNAMWOOD
Mailing Address - State:WI
Mailing Address - Zip Code:54414-0206
Mailing Address - Country:US
Mailing Address - Phone:715-449-3345
Mailing Address - Fax:715-449-3272
Practice Address - Street 1:409A MAIN ST
Practice Address - Street 2:
Practice Address - City:BIRNAMWOOD
Practice Address - State:WI
Practice Address - Zip Code:54414-0206
Practice Address - Country:US
Practice Address - Phone:715-449-3345
Practice Address - Fax:715-449-3272
Is Sole Proprietor?:No
Enumeration Date:2008-07-11
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIWI2723122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist